Odd Fellow-Rebekah Home: Resident Kicks Fight - IL
The August incident involved two residents with mobility issues who got into a physical altercation in the hallway. Federal inspectors found the facility failed to protect residents from abuse by other residents.
The aggressor, identified as R2 in the inspection report, lost both legs below the knee and uses prosthetics. She has been at the facility since March 2023 and suffers from diabetes, heart problems, and muscle weakness.
The victim, R3, has dementia with mood disturbances and gait problems. She has lived at the facility since August 2022.
On August 10, R2 told nursing staff that R3 kicked her first in her prosthetic legs, so she kicked R3 back in both lower extremities using her prosthetics.
A certified nurse aide reported to Licensed Practical Nurse V2 that R3 was complaining of leg pain and said R2 had kicked her. When V2 examined R3, she found bruising on both of the dementia patient's legs.
R2 confirmed to staff that she retaliated with her prosthetics after being kicked.
When inspectors interviewed R2 on August 22, she described the hallway encounter in detail. She said R3 was coming down the hallway and kicked her in the prosthetics, so she kicked R3 back.
Then R2 revealed something that explained her reaction.
She told inspectors she had been abused by a former spouse who hit, kicked and yelled at her. Because of that history, she said, she will not tolerate being hit by anyone and will kick or hit back anyone who attacks her first.
The facility's Director of Nursing confirmed that staff submitted an incident report on August 15 documenting the mutual combat between the two residents. The report stated that R2 kicked R3 in retaliation after being kicked in her prosthetics.
The nursing home's own abuse prevention policy, effective since March 2018, states that all residents have the right to be free from physical abuse by other residents. The policy specifically prohibits verbal, sexual, physical and mental abuse, along with corporal punishment and neglect.
But the facility failed to prevent the August 10 incident despite having two vulnerable residents with conditions that could lead to confrontation.
R3's dementia diagnosis includes mood disturbances, which can cause unpredictable behavior and aggression in patients. Her gait problems mean she likely moves unsteadily through hallways where encounters with other residents are inevitable.
R2's history of domestic violence created a hair-trigger response to any physical contact. Her prosthetic legs, designed to help her mobility, became weapons when she felt threatened.
The incident report shows the facility took five days to document what happened, submitting the final report on August 15 for an incident that occurred August 10.
During that time, R3 suffered with bruised legs while staff investigated. The licensed practical nurse who examined R3 confirmed the bruising was consistent with being kicked in both lower extremities.
Federal inspectors reviewed the facility's handling of abuse cases and found this incident represented a pattern of failing to protect residents from harm by other residents.
The inspection occurred after a complaint was filed about conditions at the 201 Lafayette Avenue East facility. Inspectors spent a day on-site examining records and interviewing staff and residents.
Odd Fellow-Rebekah Home operates as a skilled nursing facility serving residents with complex medical needs. Many residents have multiple chronic conditions requiring specialized care and supervision.
R2's medical conditions include Type II diabetes with neuropathy, heart problems, kidney disease, high blood pressure, and hypothyroidism in addition to her bilateral below-knee amputations. These conditions require constant monitoring and can affect judgment and impulse control.
The facility's failure to prevent resident-on-resident violence violated federal regulations requiring nursing homes to protect patients from all types of abuse.
When residents with cognitive impairments and histories of trauma live in close quarters, facilities must implement safeguards to prevent conflicts. This includes adequate staffing, activity programming to reduce boredom and agitation, and intervention protocols when residents show signs of distress.
The August incident shows what happens when these protections fail.
R3, already struggling with dementia and mood problems, became the target of retaliation from another vulnerable resident. Her bruised legs were physical evidence of the facility's failure to maintain a safe environment.
R2's response, while understandable given her trauma history, demonstrated the facility's failure to provide appropriate therapeutic interventions for residents with histories of abuse.
The inspection report does not indicate whether either resident received medical treatment beyond the nursing assessment that documented R3's bruises.
It also does not show what steps the facility took to prevent future incidents between these residents or others with similar risk factors.
The deficiency citation for failing to protect residents from abuse carries minimal harm designation, meaning inspectors determined the incident caused limited injury. But for R3, living with dementia in an environment where she can be physically attacked by other residents, the psychological impact may be lasting.
For R2, the incident reinforced her belief that she must defend herself physically, potentially setting up future confrontations with other residents or staff.
The facility's five-day delay in reporting suggests staff may not have initially recognized the severity of resident-on-resident violence or understood their obligation to protect all patients from harm.
Federal regulations require nursing homes to investigate and report incidents of suspected abuse immediately, not nearly a week later.
The inspection found Odd Fellow-Rebekah Home failed this basic requirement to keep residents safe from each other, leaving vulnerable patients to settle conflicts with violence in the hallways.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Odd Fellow-rebekah Home from 2025-08-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
ODD FELLOW-REBEKAH HOME in MATTOON, IL was cited for violations during a health inspection on August 23, 2025.
The August incident involved two residents with mobility issues who got into a physical altercation in the hallway.
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.
Frequently Asked Questions
- What happened at ODD FELLOW-REBEKAH HOME?
- The August incident involved two residents with mobility issues who got into a physical altercation in the hallway.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in MATTOON, IL, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from ODD FELLOW-REBEKAH HOME or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 145772.
- Has this facility had violations before?
- To check ODD FELLOW-REBEKAH HOME's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.