El Paso Rehab: Failed to Notify Family of Return - IL
The resident, identified in inspection records as R1, was taken to the emergency room at 3:12 a.m. on August 1 after experiencing "increased behaviors and delusions." Staff properly notified the guardian about the crisis and police transport to the hospital.
But when R1 returned to El Paso Rehabilitation and Health Care Center at 10:30 that morning, nobody called the guardian back.
The resident came back "yelling and agitated and crying out," according to nursing notes from that day. R1 refused to have vital signs taken and told staff "she will run again."
The guardian, who serves in that role due to R1's mental health condition, only learned about the return when she called the facility herself on August 2.
"They called me to tell me R1 was running away and they had called the police and were having R1 taken to the hospital," the guardian told inspectors on August 18. "But no one ever called me to tell me R1 came back to facility."
"It wasn't until I called them and asked them, did I know what had happened to R1. They are supposed to call me and let me know."
The administrator confirmed to federal inspectors that R1's mother had never been contacted about the resident's return from the hospital.
Federal regulations require nursing homes to immediately notify residents' families about situations that affect the resident, including transfers. The facility's own policy, updated in December 2024, specifically directs staff to notify family members about resident transfers and requires documentation of each attempt until contact is made.
The policy states: "Calls will be made to the resident's representative until they are reached. Each attempt will be charted as to the time the call was made, who was spoken to, and what information was given."
Inspectors found no record that staff attempted to contact the guardian about R1's return.
The violation represents a breakdown in communication protocols during a particularly vulnerable period for a resident with documented mental health challenges. R1's behavioral crisis was severe enough to warrant police intervention and emergency psychiatric evaluation, making family notification about the outcome especially critical.
The facility demonstrated it knew how to reach the guardian — staff successfully contacted her about the initial emergency. But the system failed during the equally important follow-up phase when the resident returned in an agitated state.
The guardian's account reveals the practical consequences of the communication failure. As R1's legal representative due to mental health issues, she was left uninformed about her ward's condition and status for more than 24 hours during a psychiatric crisis.
Federal inspectors reviewed notification practices for five residents and found this failure affected one of three residents whose cases required family notification. The inspection was conducted in response to a complaint.
The deficiency carries a "minimal harm" designation, indicating inspectors found the violation created potential for actual harm rather than immediate danger. However, the failure occurred during a mental health emergency involving a resident who had expressed intentions to "run again" upon return.
The case illustrates how administrative failures can compound during behavioral health crises in nursing homes. While staff appropriately recognized the initial emergency and involved authorities, the breakdown in follow-up communication left a guardian without critical information about her ward's psychiatric status and facility return.
The inspection report does not indicate whether similar notification failures affected other residents or families at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for El Paso Rehabilitation and Health Care Center from 2025-08-19 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
El Paso Rehabilitation and Health Care Center in EL PASO, IL was cited for violations during a health inspection on August 19, 2025.
The resident, identified in inspection records as R1, was taken to the emergency room at 3:12 a.m.
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.