Licensed Practical Nurse V37 told state inspectors she was "alone in the front of the building for approximately one and a half hours, from 10:00 PM to 11:30 PM" on January 24. She confirmed to investigators that "she did not feel this staffing level was safe or in the best interest of the residents."
The crisis deepened the next morning. When V37's shift ended at 8:00 AM on January 25, no replacement nurse had arrived. She handed her keys to the back hall nurse, V40, who became the only licensed nurse in the entire building.
V40 remained alone until nearly 11:00 AM, when Director of Nursing V2 finally arrived after being "plowed out of her driveway due to winter weather." V2 lived nearly an hour away from the facility.
During those three hours, V40 faced an emergency that highlighted the dangerous staffing levels. "A resident in the front hall experienced a seizure and fell to the floor," she told inspectors. V40 was assigned to the back halls but had to respond because she was the only nurse in the building.
"The morning was particularly stressful," V40 said. She told investigators that "resident care suffers when staffing is inadequate and resident safety is compromised."
The facility houses an average of 80 to 85 residents daily, according to its own assessment. On the night of January 24, the front half of the building had just one nurse and one certified nursing assistant. The back half was similarly understaffed.
V37 described her typical night shift conditions to inspectors. She is "always the only nurse assigned to the front halls at night," working with one CNA and one unit aide who leaves at 4:00 AM. From 4:00 AM to 6:00 AM, she said, "the front halls require two CNAs to assist residents with toileting and morning care."
Instead, she has one.
"During this time, she begins her early morning medication pass and is unable to consistently assist the sole CNA," the inspection report states.
V40 told investigators the facility "is often short-staffed, especially on weekends." She said nurses "are unable to perform their duties effectively and must rush through tasks when staffing levels are insufficient."
Director of Nursing V2 acknowledged the crisis to inspectors, confirming that "staffing levels from 1/24/26 to 1/25/26 were very low due to winter weather conditions." But she revealed the problem extends far beyond weather emergencies.
"Staffing shortages are an ongoing issue," V2 told inspectors. The facility "utilizes multiple agency staff members who frequently call off, resulting in the facility being short-staffed."
Federal regulations require nursing homes to provide sufficient staff to meet residents' needs for safety and quality care every day. The inspection found Palm Garden failed to meet this standard, with the potential to affect all 94 residents.
The January 24-25 weekend illustrates how quickly inadequate baseline staffing can become dangerous. When agency staff called off due to weather, the facility had no backup plan that didn't involve leaving residents essentially unattended by licensed nurses for hours.
V37's account reveals the impossible position nurses face under these conditions. After working alone for 90 minutes during her night shift, she still had to leave at 8:00 AM because "there was no one available to replace her." The Director of Nursing was unreachable, buried under snow an hour away.
The seizure incident demonstrates the medical emergencies that don't wait for adequate staffing. V40 was responsible for medication passes, treatments, and emergency responses across the entire facility while V2 drove through winter weather to reach work.
Both nurses told inspectors they felt resident safety was compromised. V40 said she had to "rush through tasks" to cover the impossible workload. V37 stated flatly that the staffing level was unsafe.
The facility's own assessment acknowledges its goal to "maintain sufficient staffing to ensure an adequate number of qualified staff are available to meet each resident's needs." The January weekend showed how far reality fell short of that goal.
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.