Palm Garden of Mattoon: Unsafe Discharge Practices - IL
The first resident, identified in inspection records as R107, had been complaining of dizziness for "a few days" before she fell on January 1, 2025. A visitor told inspectors R107 ended up in the emergency room with a large bruise on her sacral area. On January 8, therapy walked R107 to the dining room and left her there without a wheelchair. The visitor said R107 was scared to walk alone and wanted the wheelchair, and would have used it if one had been available.
The facility's own regional registered nurse told inspectors on January 29 that the facility had no documentation showing fall interventions were in place at the time of either fall, and that a wheelchair should have been left with R107 so she would not have tried to walk to another chair on her own.
The second resident, R7, was found sitting on the floor beside her bed on December 17, 2025, with the left side rail on the floor next to her. She told staff she had tried to use the rail to sit up and it fell off the bed frame, taking her with it. A physician had ordered the rail specifically to help R7 with bed mobility. R7 had a right above-the-knee amputation, a fractured left tibia, lack of coordination, and gait abnormalities.
The maintenance director told inspectors that nursing staff routinely remove and reinstall side rails without securing them properly to the bed frames, and said that is what he believes happened before R7's fall. The director of nurses confirmed only maintenance staff are authorized to install bedrails, and confirmed the rail was not secured and posed a hazard that caused R7 to fall.
The facility is disputing the citation. It received an actual harm rating, meaning inspectors concluded a resident was injured as a result of the deficiency.
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 first resident, identified in inspection records as R107, had been complaining of dizziness for "a few days" before she fell on January 1, 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.