Odd Fellow-Rebekah Home: No Trauma Care Plan - IL
The resident, identified as R2 in inspection documents, has both legs amputated below the knee and uses prosthetics. She told inspectors on August 22 that she was "abused (hit and kicked, yelled at) by a former spouse and will not take being hit by anyone and will be kicking/hitting everyone back that hits/kicks/yells at R2."
That same day, the resident demonstrated exactly what she meant. When another resident came down the hallway and kicked her in the prosthetics, she kicked back with her prosthetic legs.
Federal inspectors found that Odd Fellow-Rebekah Home failed to develop any care plan addressing the resident's trauma history or her reactive behaviors during their August 23 complaint investigation.
The facility's own policy requires comprehensive, person-centered care plans that address residents' "medical, physical, mental and psychosocial needs." The policy, dated November 2017, mandates that care plans include "goals, measurable objectives, and interventions to meet identified resident needs."
The Director of Nurses confirmed during the inspection that R2 "did not have a person centered care plan." The medical record contained no trauma-centered care plan and no interventions for the resident's documented pattern of verbal aggression toward other residents.
R2 has been at the facility since March 14, 2023. Her medical diagnoses include generalized muscle weakness, Type II diabetes with diabetic neuropathy, heart conditions, kidney disease, and the acquired absence of both legs below the knee.
A Licensed Practical Nurse told inspectors that R2 "has talked about being verbally/physically abused by a former spouse." The nurse noted that R2 "can be verbally aggressive and yell at others."
The resident's trauma history appears to directly influence her current behaviors. She explicitly connected her past abuse to her current defensive reactions, explaining she would fight back against anyone who hits, kicks, or yells at her.
Despite this clear link between trauma and behavior, and despite the resident's willingness to discuss her history with staff, the facility developed no specialized interventions.
The facility's care plan policy requires that all plans be "reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly assessment." This means the oversight wasn't a one-time failure but an ongoing gap that should have been caught during regular reviews.
The incident between R2 and another resident occurred in a hallway, where R2 was vulnerable to being kicked in her prosthetics. Her immediate response was to kick back with those same prosthetics, exactly as she had warned staff she would do.
The absence of a trauma-informed care plan leaves both R2 and other residents at risk. Without proper interventions, staff have no systematic approach to help R2 manage her trauma responses or to prevent situations that might trigger her defensive behaviors.
Federal regulations require nursing homes to provide person-centered care that addresses the whole person, not just medical diagnoses. For residents with trauma histories, this specifically includes developing approaches that recognize how past experiences shape current behaviors.
The violation occurred despite R2's openness about her history and her clear explanation of how it affects her interactions with others. She told staff exactly what would trigger her defensive responses and what those responses would look like.
The Licensed Practical Nurse's acknowledgment that R2 discusses her abuse history and displays verbal aggression shows that staff are aware of both the trauma and its behavioral manifestations. Yet this awareness never translated into a formal care plan.
R2's multiple medical conditions, including the loss of both legs below the knee, already require complex care coordination. The addition of trauma-related behavioral needs makes comprehensive planning even more critical.
The facility's policy explicitly states that care plans should honor "resident rights to choice" while meeting their needs. R2 has made her choices clear: she will defend herself against perceived threats, using her prosthetic legs if necessary.
Without interventions that acknowledge this reality and work with it rather than against it, the facility cannot provide the person-centered care its own policies promise.
The August 22 incident demonstrates that R2's trauma responses are not theoretical concerns but active behavioral patterns that affect daily life at the facility. Her willingness to kick back when kicked shows that her defensive behaviors can escalate physical confrontations.
The inspection found that facility policy required care plans to include measurable objectives and specific interventions. For R2, this could have meant strategies for helping her feel safe, techniques for de-escalating situations before they become physical, or environmental modifications to reduce triggers.
Instead, nearly two and a half years after her admission, R2 navigates the facility with no formal support system for managing her trauma responses.
The Director of Nurses' confirmation that no person-centered care plan existed indicates a fundamental failure in the facility's care planning process. This wasn't a case of an inadequate plan, but of no specialized plan at all.
R2's case illustrates how trauma histories can remain invisible in nursing home care, even when residents are willing to discuss them openly. Her straightforward explanation of her abuse history and her behavioral responses provided a clear roadmap for developing appropriate interventions.
The facility missed that opportunity, leaving a vulnerable resident to manage her trauma responses alone while potentially putting other residents at risk of her defensive behaviors.
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 20, 2026 · Our methodology
ODD FELLOW-REBEKAH HOME in MATTOON, IL was cited for violations during a health inspection on August 23, 2025.
The resident, identified as R2 in inspection documents, has both legs amputated below the knee and uses prosthetics.
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.