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Complaint Investigation

Odd Fellow-rebekah Home

August 23, 2025 · Mattoon, IL · 201 Lafayette Avenue East
Citations 2
CMS Rating 1/5
Beds 162
Provider ID 145772
Healthcare Facility
Odd Fellow-rebekah Home
Mattoon, IL  ·  View full profile →
Inspection Summary

ODD FELLOW-REBEKAH HOME in MATTOON, IL — inspection on August 23, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

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 (R2, 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 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 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 R2 stated R3 kicked R2 first and R2 kicked 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 R2 kicked R3 in retaliation for R3 kicking R2 in the bilateral lower prosthetics.

The same report documents R2 used her prosthesis to kick 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 R3 was complaining of pain to her legs, R3 stated R2 kicked her in the legs. V2 stated R3 had bruising to bilateral lower extremities. V2 confirmed R2 stated R3 kicked R2's Bilateral Lower prosthetics and R2 kicked R3 back with the prosthesis in the bilateral lower extremities. On 8/22/25 at 12:30pm R2 stated R3 was coming down the hallway and kicked R2 in the prosthetics and R2 kicked R3 back. 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

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/23/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Odd Fellow-Rebekah Home

201 Lafayette Avenue East Mattoon, IL 61938

SUMMARY STATEMENT OF DEFICIENCIES

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 (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 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 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 R2. R2 stated R3 was coming down the hallway and kicked R2 in the prosthetics and R2 kicked R3 back with the prosthetics.On 08/22/25 at 2:12pm V2 Licensed Practical Nurse stated R2 has talked about being verbally/physically abused by a former spouse. V2 stated that R2 can be verbally aggressive and yell at others.On 08/22/25 at 2:00pm V1 Director of Nurses stated R2 did not have a person centered care plan. V1 confirmed R2's medical record did not contain a Trauma Centered Care Plan nor interventions for R2's behaviors of being verbally aggressive (yelling) at/with other residents.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MATTOON, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ODD FELLOW-REBEKAH HOME or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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