F0725

F

Insufficient Licensed Nurse and CNA Staffing Across Multiple Shifts

Mattoon, Illinois Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient licensed nurses and CNAs on multiple shifts to meet residents’ needs for safety and quality of care. The facility assessment documented an average daily census of 80–85 residents and a goal to maintain adequate qualified staff to meet each resident’s needs. However, the daily nursing schedules showed that on the night shift of 1/24/26 there was only one nurse and one CNA assigned to the front half of the building, and on the day shift of 1/25/26 there was only one nurse in the entire building until 11:00 AM. An LPN assigned to the front hall on the night shift of 1/24/26 reported being alone in the front of the building for approximately one and a half hours, from 10:00 PM to 11:30 PM, before any other staff arrived, and confirmed she did not feel this staffing level was safe or in the best interest of residents.

The same LPN stated she is always the only nurse assigned to the front halls at night, typically with one CNA and one unit aide, and that from 4:00 AM to 6:00 AM the front halls require two CNAs for toileting and morning care while she is occupied with the early morning medication pass and unable to consistently assist the sole CNA. The DON confirmed that staffing levels on 1/24/26–1/25/26 were very low, that the DON did not arrive until close to 11:00 AM, and that one LPN was the only nurse in the building from 8:00 AM until nearly 11:00 AM. That LPN reported being assigned to the back halls while a resident in the front hall experienced a seizure and fell to the floor during this period, and stated that the facility is often short-staffed, especially on weekends, causing resident care to suffer and resident safety to be compromised, with nurses having to rush through their duties when staffing is inadequate.