Palm Garden of Mattoon: Staffing Failures Leave Residents at Risk - IL
The licensed practical nurse assigned to the front hall at Palm Garden of Mattoon that Saturday night had one certified nursing assistant working alongside her and a unit aide who was scheduled to leave at 4:00 AM. From 10:00 PM to 11:30 PM, before any additional staff arrived, she was the only licensed nurse covering her section of a building that housed more than 80 residents.
She told inspectors she did not feel the staffing level was safe or in the best interest of the residents.
When her shift ended the next morning, it got worse.
The nurse, identified in the inspection report as V37, needed to leave at 8:00 AM. No replacement was available. The Director of Nursing agreed to come in, but she lived nearly an hour away and had to be plowed out of her driveway because of winter weather. V37 handed her keys to the nurse covering the back hall and walked out. For three hours, from 8:00 AM until the Director of Nursing arrived close to 11:00 AM, a single nurse was responsible for every resident in the entire building.
That nurse, V40, was assigned to the back halls. She told inspectors the morning was particularly stressful. A resident in the front hall had a seizure and fell to the floor. V40 was the only nurse on duty. She described the morning as a situation where resident safety was compromised, where nurses could not perform their duties effectively and had to rush through tasks.
"Resident care suffers when staffing is inadequate," V40 told inspectors on January 29th.
The Director of Nursing, V2, confirmed all of it. She told inspectors that staffing levels during that stretch were very low because of the weather, that V40 was indeed the only nurse in the building for nearly three hours, and that staffing shortages are an ongoing issue at the facility. She said the facility relies heavily on agency staff, who frequently call off, leaving Palm Garden short-handed on a regular basis.
The facility's own assessment documents an average daily census of 80 to 85 residents.
V37 told inspectors the overnight coverage arrangement on the front hall is not a weather emergency exception. She said she is always the only nurse assigned to the front halls at night, typically paired with one CNA and one unit aide. The unit aide leaves at 4:00 AM. From 4:00 AM to 6:00 AM, she said, two CNAs are needed to help residents with toileting and morning care, but she is usually beginning her medication pass by then and cannot consistently assist the one CNA left on the floor.
The inspection was a complaint investigation. The violation was cited at the level of minimal harm or potential for actual harm, a classification that covers situations where conditions have not yet produced documented injury but carry clear risk. Federal inspectors noted the staffing failure had the potential to affect all 94 residents currently residing at the facility.
Palm Garden of Mattoon's own stated goal, written into its facility assessment, is to maintain sufficient staffing to ensure an adequate number of qualified staff are available to meet each resident's needs.
On the morning of January 25th, when a resident was seizing on the floor of the front hall, there was one nurse in the building.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
PALM GARDEN OF MATTOON in MATTOON, IL was cited for violations during a health inspection on January 29, 2026.
She told inspectors she did not feel the staffing level was safe or in the best interest of the residents.
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.