The nurse, identified as V37, told state inspectors she was abandoned from 10:00 PM to 11:30 PM on January 24 while waiting for additional staff to arrive. When her shift ended at 8:00 AM the next morning, no replacement existed to take over her duties.
"I did not feel this staffing level was safe or in the best interest of the residents," V37 told inspectors on January 29.
The situation deteriorated further when V37 left her keys with the back hall nurse, making that person the only licensed nurse in the entire 94-bed facility. That nurse, V40, worked alone until nearly 11:00 AM while a resident in the front hall suffered a seizure and fell to the floor.
"The morning was particularly stressful," V40 told inspectors, describing the emergency that occurred while she was the sole nurse responsible for the building's 80-85 residents.
Director of Nursing V2 eventually arrived to help around 11:00 AM, but only after being plowed out of her driveway due to winter weather. She lived nearly an hour away from the facility.
V37 described her typical night shift assignments as inherently inadequate. She works alone as the only nurse for the front halls, usually with one certified nursing assistant and one unit aide. The unit aide leaves at 4:00 AM, creating a two-hour gap when V37 begins medication rounds while only one CNA handles toileting and morning care for multiple residents.
"From 4:00 AM to 6:00 AM, the front halls require two CNAs to assist residents with toileting and morning care," V37 explained. "I am unable to consistently assist the sole CNA" during medication distribution.
The Director of Nursing acknowledged the crisis to inspectors. V2 confirmed that staffing shortages represent "an ongoing issue" at the facility, which relies heavily on agency staff who "frequently call off."
V40, the nurse who worked alone during the seizure emergency, told inspectors that inadequate staffing compromises both care quality and resident safety. She said nurses "are unable to perform their duties effectively and must rush through tasks when staffing levels are insufficient."
The facility's own assessment documents an average daily census of 80-85 residents, with a stated goal of maintaining sufficient staffing to meet each resident's individual needs. State inspectors found this goal was not met during the inspection period.
Weekend shifts appeared particularly vulnerable to staffing failures. V40 told inspectors "the facility is often short-staffed, especially on weekends."
The inspection revealed systematic understaffing that affected the facility's 94 licensed beds. Daily nursing schedules showed multiple instances where minimum safe staffing levels were not maintained, including the night shift of January 24 when only one nurse and one CNA covered half the building.
Federal regulations require nursing homes to provide sufficient nursing staff every day to meet residents' needs and maintain a licensed nurse in charge on each shift. The inspection found Palm Garden failed to meet these requirements, creating potential for actual harm to many residents.
V40's description of the morning emergency illustrated the real-world consequences of inadequate staffing. While she rushed between the back halls and front halls during the seizure incident, other residents' needs went unmet.
The facility's reliance on agency staff created additional instability. When external workers called off during winter weather, permanent staff faced impossible workloads with no backup systems in place.
V37's experience highlighted the personal toll on nurses forced to work in unsafe conditions. After spending hours alone responsible for dozens of vulnerable residents, she had to abandon her post when no replacement arrived, leaving the building even more understaffed.
The inspection documented these failures affected all residents in the facility, not just those directly involved in the seizure emergency. When nurses must "rush through tasks" due to insufficient staffing, every resident's care suffers.
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.