The staffing crisis unfolded over 24 hours in late January when winter weather prevented workers from reaching the nursing home. Federal inspectors found the dangerous conditions violated requirements to provide sufficient nursing staff to meet residents' safety needs.
V37, a licensed practical nurse assigned to the front halls during the night shift of January 24, told inspectors she was completely alone from 10:00 PM to 11:30 PM before any other staff arrived. She confirmed she did not feel this staffing level was safe or in the best interest of residents.
The situation worsened at shift change. V37 needed to leave at 8:00 AM but no replacement had arrived. The Director of Nursing agreed to come in but lived nearly an hour away and had to be plowed out of her driveway due to winter weather conditions.
V37 left at 8:00 AM and handed her keys to the back hall nurse, who then became the only nurse on duty in the entire building.
V40, the licensed practical nurse who received those keys, worked alone until nearly 11:00 AM when the Director of Nursing finally arrived. During those three hours, V40 was responsible for all 94 residents at the facility.
The morning became particularly stressful when a resident in the front hall experienced a seizure and fell to the floor. V40 was assigned to the back halls but had to respond as the facility's only nurse.
"The morning was particularly stressful," V40 told inspectors, describing the seizure incident while she covered the entire building alone.
V40 said she feels resident care suffers when staffing is inadequate and resident safety is compromised. Nurses are unable to perform their duties effectively and must rush through tasks when staffing levels are insufficient, she explained.
The Director of Nursing confirmed the dangerous staffing levels from January 24 to January 25 were very low due to winter weather conditions. She stated she came to the facility Sunday morning to cover the shift and arrived close to 11:00 AM, confirming V40 was the only nurse in the building for nearly three hours.
But weather was not the only problem. The Director of Nursing told inspectors that staffing shortages are an ongoing issue at Palm Garden of Mattoon. The facility utilizes multiple agency staff members who frequently call off, resulting in the facility being short-staffed.
V37 described her typical overnight assignment as always being the only nurse for the front halls at night. She typically has one certified nursing assistant and one unit aide, but the unit aide only works from 10:00 PM to 4:00 AM.
From 4:00 AM to 6:00 AM, the front halls require two certified nursing assistants to help residents with toileting and morning care. During this critical time, V37 begins her early morning medication pass and is unable to consistently assist the sole remaining aide.
V40 confirmed that the facility is often short-staffed, especially on weekends.
The facility's own assessment documents an average daily census of 80 to 85 residents. The facility's stated goal is to maintain sufficient staffing to ensure an adequate number of qualified staff are available to meet each resident's needs.
Federal inspectors found the facility failed to provide a sufficient number of licensed nurses and certified nursing assistants to meet residents' needs for safety and quality of care. The violation has the potential to affect all 94 residents residing in the facility.
The inspection occurred after a complaint was filed about conditions at the facility.
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.