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Complaint Investigation

Odd Fellow-rebekah Home

November 26, 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 November 26, 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

FF0755
Pharmacy Service Deficiencies
Potential for More Than Minimal Harm

nurse can call the regular pharmacy provider, which has an on-call service available 24 hours per day; however, the on-call service might be located in California. V2 further stated that the on-call service would call area pharmacies to locate one able to fill the needed medication. V2 additionally stated that if a resident is out of a medication, they typically only need one or two doses before the regular pharmacy delivery arrives, making it difficult to find a pharmacy willing to fill an order for one or two pills, especially if the facility is not a regular customer. V2 concluded by stating that the special on-call delivery might still take up to 12 hours, at which point it would be just as effective to wait for the regular daily pharmacy delivery.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Odd Fellow-Rebekah Home

201 Lafayette Avenue East Mattoon, IL 61938

SUMMARY STATEMENT OF DEFICIENCIES

Ensure that residents are free from significant medication errors.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that a resident was free from a significant medication error involving an anti-seizure medication.

This failure affected one resident (R2) out of three reviewed for anti-seizure medications on the sample list of three.Findings include: R2's Census Detail dated 11/25/25 documented that R2 was admitted to the facility on [DATE].R2's Medical Diagnoses List dated 11/25/25 documented that R2's medical diagnoses included epilepsy.R2's Physician Prescription Facsimile from the neurologist (V6), dated 9/22/2025, documented an order for R2 to take two tablets of Keppra 250 milligrams (mg) by mouth twice a day, totaling 500 mg twice daily.R2's Physician Order Sheet entry dated 6/12/2024 documented an order for R2 to receive Levetiracetam oral tablets, 250 mg, to be given by mouth twice a day.On 11/25/2025 at 11:45 a.m., V3, Licensed Practical Nurse, stated she gave R2 one tablet of Keppra 250 mg that morning during her medication administration pass. V3 verified the order in R2's Medication Administration Record (MAR) as one tablet of Keppra 250 mg by mouth twice a day.On 11/25/2025 at 11:55 a.m., a bubble pack of Keppra 500 mg was observed for R2, documenting that one 500 mg tablet was to be given by mouth twice a day.

The bubble pack was retrieved from the medication cart by V3.

Handwritten on the medication bubble pack was 1/2 tab. V3 stated that 1/2 tab indicated one-half of a tablet was to be given at each dose, equaling a 250 mg dose twice daily.On 11/25/2025 at 12:15 p.m., R2's MAR documented that R2 had been administered Keppra 250 mg by mouth twice a day from 9/1/2025 through the morning dose on 11/25/2025.On 11/25/25 at 2:48 p.m., V2, Director of Nursing, confirmed that the most recent physician order from the neurologist (V6) was for Keppra 250 mg with instructions to administer two 250 mg tablets twice daily, for a total of 500 mg twice daily. V2 stated the facsimile did not have a signature from facility nursing staff and the document must have been uploaded into R2's electronic medical record prior to the nurses transcribing the new order onto R2's Physician Order Sheet. V2 confirmed that the current dose should be 500 mg twice daily.

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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