Palm Garden Mattoon: Range of Motion Care Gaps - IL
The resident, identified in inspection records as R7, had a physician's order requiring the left half side rail to remain up while she was in bed. She had a fractured left tibia, lack of coordination, gait abnormalities, muscle wasting, and a right above-the-knee amputation. The rail was supposed to help her move in bed. On December 17, 2025, it came off the frame when she reached for it.
The maintenance director told inspectors that nursing staff routinely remove and replace bed rails without securing them properly. He said that is what he believes happened before R7's fall. The director of nurses confirmed that only maintenance staff are authorized to install bed rails, and confirmed the rail was not secured when R7 fell.
A second resident, R107, fell twice in early January 2025. Staff knew for several days before her first fall on January 1 that she had been feeling unwell and was getting dizzy when she stood up. No additional supervision was put in place. On January 8, a therapy staff member walked R107 to the dining room and left her there without a wheelchair, despite R107 being at a point in her care where she was supposed to use one. R107 wanted the wheelchair. She was scared to walk alone and would have used it. She did not have one available to her.
The regional registered nurse who reviewed the records told inspectors the facility had no documentation showing fall interventions were in place at the time of either fall. She also noted R107 did not have a bedside table in her room, which she described as standard equipment, and said she did not know why it was missing.
The facility is disputing the citation.
R7 fell onto the floor beside the rail that was supposed to hold her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Palm Garden of Mattoon from 2026-01-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PALM GARDEN OF MATTOON in MATTOON, IL was cited for violations during a health inspection on January 29, 2026.
The resident, identified in inspection records as R7, had a physician's order requiring the left half side rail to remain up while she was in bed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.