Palm Garden of Mattoon: Resident Property Theft Risk - IL
The fall happened on December 17, 2025. The resident, identified in inspection records as R7, had a physician's order for a left half side rail in the up position specifically to help her move in bed. She has a right above-the-knee amputation, a fractured left tibia, muscle wasting, and lack of coordination. The rail was supposed to help her. Instead it failed.
The maintenance director told inspectors that nursing staff routinely remove and reinstall bed rails without securing them properly to the frame. He said he believed that's what happened with R7's rail. The director of nurses confirmed it: the rail was not secured, it posed a hazard, and that hazard caused the fall. She also confirmed that only maintenance staff are authorized to remove and install bed rails.
A second resident, R107, fell twice in eight days. On January 1, staff knew she had been feeling unwell for days and was complaining of dizziness when standing. No closer supervision was arranged. She fell. On January 8, a therapy worker walked her to the dining room and left without providing a wheelchair, even though R107 was supposed to have one. She fell again.
A family member told inspectors R107 was scared to walk alone and would have used the wheelchair if one had been there. She wanted it. She just didn't have it.
The facility's own regional nurse confirmed on January 29 that there was no documentation showing fall prevention interventions were in place at the time of either fall. She also noted R107 did not have a bedside table in her room, describing it as standard equipment and saying she didn't know why it was missing.
Palm Garden of Mattoon is disputing the citation.
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 22, 2026 · Our methodology
PALM GARDEN OF MATTOON in MATTOON, IL was cited for violations during a health inspection on January 29, 2026.
The fall happened on December 17, 2025.
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.