Odd Fellow-rebekah Home

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of three residents (Resident R2, Resident R3) reviewed for abuse in the sample list of five.Findings Include:The Facility Abuse Prevention and Reporting policy effective 3/15/2018, documents this facility affirms: 1. All residents have the right to be free of from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. On 8/23/25 at 12:23pm Resident R2's Care Plan documents an admission date of 03/14/2023 with diagnoses of Muscle Weakness (generalized), Type II Diabetes Mellitus with Diabetic Neuropathy, Paroxysmal Atrial Fibrillation, Hyperlipidemia, Glaucoma, Essential (Primary) Hypertension, Hypothyroidism, Chronic Kidney Disease, Acquired Absence of Right Leg Below Knee, Chronic Diastolic (Congestive) Heart Failure, and Acquired Absence of Left Leg Below Knee. On 8/23/25 at 12:27pm Resident R3's Care Plan documents an admission date of 08/11/2022 with diagnoses of Abnormalities of Gait and Mobility, Muscle Weakness, Essential (Primary) Hypertension, Glaucoma, Dementia, Unspecified Severity, with Mood Disturbance, and Depressive Disorders. The Nurse Progress Note dated 8/10/2025 at 5:00pm documents Resident R2 stated Resident R3 kicked Resident R2 first and Resident R2 kicked Resident R3 back in the bilateral lower extremities. On 8/22/25 at 2:00pm V1 Director of Nursing confirmed the facility submitted a final facility reported incident dated 08/15/25 that stated Resident R2 kicked Resident R3 in retaliation for Resident R3 kicking Resident R2 in the bilateral lower prosthetics.

The same report documents Resident R2 used her prosthesis to kick Resident R3 in the bilateral lower extremities. On 8/22/25 at 2:12pm V2 Licensed Practical Nurse stated a Certified Nurse Aide reported to her that Resident R3 was complaining of pain to her legs, Resident R3 stated Resident R2 kicked her in the legs. V2 stated Resident R3 had bruising to bilateral lower extremities. V2 confirmed Resident R2 stated Resident R3 kicked Resident R2's Bilateral Lower prosthetics and Resident R2 kicked Resident R3 back with the prosthesis in the bilateral lower extremities. On 8/22/25 at 12:30pm Resident R2 stated Resident R3 was coming down the hallway and kicked Resident R2 in the prosthetics and Resident R2 kicked Resident R3 back. Resident R2 stated 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 hit/kicks/yells at her.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Odd Fellow-Rebekah Home

201 Lafayette Avenue East Mattoon, IL 61938

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for trauma/abuse for one of three residents (Resident R2) reviewed for abuse in the sample list of five.Findings include:The Care Plan Process policy dated 11/2017 documents a comprehensive person-centered care plan shall be developed and implemented to meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs, while honoring resident rights to choice. This care plan shall include goals, measurable objectives, and interventions to meet identified resident needs.

The same document states all plans of care must be reviewed and revised by the interdisciplinary team

after each assessment, including both the comprehensive and quarterly assessment.On 8/23/25 at 12:23pm Resident R2's care plan documents an admission date of 03/14/2023 with diagnoses of Muscle Weakness (generalized), Type II Diabetes Mellitus with Diabetic Neuropathy, Paroxysmal Atrial Fibrillation, Hyperlipidemia, Glaucoma, Essential (Primary) Hypertension, Hypothyroidism, Chronic Kidney Disease, Acquired Absence of Right Leg Below Knee, Chronic Diastolic (Congestive) Heart Failure, and Acquired Absence of Left Leg Below Knee.On 08/22/25 at 12:30pm Resident R2 stated 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 Resident R2. Resident R2 stated Resident R3 was coming down the hallway and kicked Resident R2 in the prosthetics and Resident R2 kicked Resident R3 back with the prosthetics.On 08/22/25 at 2:12pm V2 Licensed Practical Nurse stated Resident R2 has talked about being verbally/physically abused by a former spouse. V2 stated that Resident R2 can be verbally aggressive and yell at others.On 08/22/25 at 2:00pm V1 Director of Nurses stated Resident R2 did not have a person centered care plan. V1 confirmed Resident R2's medical record did not contain a Trauma Centered Care Plan nor interventions for Resident R2's behaviors of being verbally aggressive (yelling) at/with other residents.

Event ID:

Facility ID:

If continuation sheet