Palm Garden of Mattoon

In the surveyor’s words

From the most serious findings on record at Palm Garden of Mattoon, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 2, 2026

  Based on observation, interview and record review, the facility failed to provide supervision and ensure a door alarm was audible to staff to prevent a cognitively impaired resident with exit seeking behaviors from eloping from the facility for one of four residents (R4) reviewed for elopement in the sample list of 40 residents. R4 was found eight blocks from the facility by a citizen who called emergency services when they saw R4 wandering in the road. These failures resulted in R4 falling and suffering abrasions to R4's palm and knee and R4 being exposed to significant danger including road hazards, uneven terrain and railroad tracks. […]

• Actual harm, isolatedF600Aug 20, 2026

  Based on interview and record review the facility failed to protect resident's right to be free from resident-to-resident physical, verbal, and emotional abuse from another resident. This failure affected five (R1, R2, R3, R5, R6) of six residents reviewed for abuse on the sample list of six residents. These failures caused residents emotional distress and verbalizing not feeling safe in the facility. Findings Include: The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated April 2021 documents each resident has the right to be free from abuse including but not limited to verbal, mental, and physical abuse.R1's Medical Diagnoses list dated August 2026 documents R1 is diagnosed with Major Depressive Disorder and Generalized Anxiety Disorder.R1's Minimum… […]

• Actual harm, isolatedF600Jan 29, 2026

  Based on interview and record review the facility failed to protect a resident's right to be free from staff to resident physical and emotional abuse which caused skin tears to the resident's arm and severe emotional distress. This failure affected one of three residents (R93) reviewed for abuse on the sample list of 39. Findings Include: The facility's Abuse Prevention Program dated February 2021 documents that the facility affirms residents' rights to be free from abuse. This includes freedom from physical restraint, mistreatment, or abuse of any resident. Abuse is defined as the willful infliction of injury, intimidation, or punishment resulting in harm, pain, or mental anguish. […]

• Actual harm, isolatedF686Jan 29, 2026

  Based on interview and record review the facility failed to implement pressure relieving measures timely, failed to complete a thorough skin assessment weekly and failed to prevent one (R107) resident's right heel pressure ulcer from worsening to a stage IV out of three residents reviewed for pressure ulcers in a sample list of 39 residents. R107 obtained a Stage IV pressure ulcer to her right heel at the facility. Findings include:R107's undated Face Sheet documents R107 was admitted to the facility on [DATE].R107's Electronic Medical Record (EMR) documents medical diagnoses of chronic respiratory failure with hypoxia, cognitive communication deficit, vitamin D deficiency, asthma with acute exacerbation, atelectasis, iron deficiency, delusional disorder, pulmonary embolism without acute… […]

• Actual harm, isolatedF689Jan 29, 2026

  Based on interview and record review, the facility failed to implement fall prevention interventions and failed to maintain a safe environment for two residents (R7 and R107) out of six residents reviewed for falls in a sample of 39 residents. R107 experienced pain and fear as a result of falling, as well as a closed head injury and multiple contusions following a fall on 1/1/25. R107 required further evaluation of her injuries in an emergency room following falls on 1/1/25 and 1/8/25 due to having a physician order for Xarelto (anticoagulant therapy). […]