Casey Rehab and Nursing: Dementia Elopement Failures - IL
The resident, identified in inspection records only as R7, had already been flagged as high risk for elopement. His diagnosis included dementia with agitation and anxiety disorder. For weeks, he had been fixated on a single worry: getting to the bank to pay his rent. The facility knew this. Notes from a licensed practical nurse five days earlier documented that R7 had exit-sought twice in one shift, that staff tried to redirect him, and that re-education had failed because of his cognitive decline. A note from August 11 documented three more exit attempts in a single day.
The first incident on August 13 happened around 10:30 a.m. A certified nursing assistant ran outside and brought R7 back in, walking him to the business office, where the business office manager took over. Less than two hours later, at 12:10 p.m., R7 was outside again. This time the Director of Nursing ran out and retrieved him.
Four minutes after that, the Director of Nursing told inspectors that R7 was "very agitated today," that he worried constantly about going to the bank and paying his bills, and that he was progressively declining. She said staff should be doing 15-minute checks and making sure his needs were being met. Then she said something that caught the inspector's attention: the business office manager, the person staff had handed R7 to after the first incident that morning, had not completed dementia training and "may not know what to do with/for R7."
The administrator, interviewed at 12:57 p.m., said R7 had been placed on one-to-one supervision after a previous elopement attempt. He said R7 had only started going to the door again in the last two to three days. He described the interventions in place: an alarm bracelet, a calendar showing when rent was due, and access to a courtyard. He also said dementia training should be completed during onboarding, before staff begin working.
The LPN who had been documenting R7's exit attempts told inspectors the only options she saw were to follow him around, walk with him, and keep repeating things to help him remember. "This man goes out the door about every day," she said, "and it has been going on for the last week and a half on a daily basis."
Two registered nurses, interviewed separately that afternoon, said they did not know where the facility's elopement logbook was kept. One said she had never been shown where it was. The other, described as still relatively new, said she wasn't sure either. The facility's own wandering and elopement policy, last revised in June 2024, states that all departments shall be made aware of the elopement log and its location. The same policy describes a "multi-faceted approach" to elopement prevention that includes staff education on wandering, and the responsibility of staff to identify, report, and intervene for residents at risk.
The Director of Nursing told inspectors, at 1:45 p.m., that the facility was planning to move R7 to the south hall, a locked unit. She also said nurses should have been documenting the follow-up from each elopement and the interventions used.
R7 was still on the open unit when inspectors left. His care plan had identified him as high elopement risk. His own nurses had documented that he was walking out the front door every day. The business office manager who sat with him after the first incident that morning had never been trained in dementia care. And two of the nurses responsible for his safety could not find the logbook meant to track every time a resident like him tried to leave.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Casey Rehab and Nursing from 2025-08-13 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 3, 2026 · Our methodology
CASEY REHAB AND NURSING in CASEY, IL was cited for violations during a health inspection on August 13, 2025.
The resident, identified in inspection records only as R7, had already been flagged as high risk for elopement.
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.