El Paso Rehab: Elopement Risk Assessment Failure - IL
Inspectors cited El Paso Rehabilitation and Health Care Center following a complaint inspection completed May 26, 2026, for failing to accurately assess the resident, identified in records as R1, as someone at risk of walking out of the building.
The facility's own elopement risk form, dated March 5, 2026, asked staff to consider whether the resident had a desire to leave the building, exit-seeking behavior, or a history of wandering. The form was explicit: check any of those boxes, and the resident is at risk. Put interventions in place. Build a care plan around it.
None of that happened.
V17, a Social Service Aide who told inspectors she conducts the elopement risk assessments, described R1's condition in detail during an interview on May 19. R1 had a diagnosis of Alzheimer's and psychosis. He experienced delusions and hallucinations. He fixated on the family farm. He told staff, repeatedly, that his family was coming to get him and take him there.
That is a man who believes, with conviction, that he has somewhere to be and someone coming to take him there.
V17 and V4, a Licensed Practical Nurse who also serves as the facility's care plan coordinator, both reviewed the elopement risk assessment with inspectors. Both acknowledged that R1 should have been flagged as an elopement risk. Both acknowledged that interventions should have been put in place. Neither could explain why they weren't.
R1's care plan and his Minimum Data Set, the standardized federal assessment used to track resident needs and risks, contained no mention of his exit-seeking behaviors.
The facility's elopement policy, approved in September 2025, states that all residents identified as elopement risks will have those issues addressed in their individual care plans. The care planning policy, approved in December 2024, requires that every resident be assessed using the Minimum Data Set. The gap between what those policies promised and what R1's records actually contained was total.
Inspectors rated the violation at the minimal harm level, meaning no documented incident had occurred by the time of the inspection. R1 had not walked out. But the risk assessment process that exists to prevent exactly that had failed him completely, and the people responsible for completing it confirmed as much themselves.
Elopement, in the nursing home context, means a resident leaving unsupervised and unsafely. For residents with dementia, it carries serious consequences. A person who believes, with the certainty that psychosis can produce, that his family is on the way and the farm is waiting, does not experience the locked door or the unfamiliar hallway the way a fully oriented person would. He experiences an obstacle between himself and something real.
The facility had the information it needed. V17 knew about the farm. She knew about the delusions. She filled out the form anyway and left the risk unchecked. R1's care plan went on without a word about any of it.
What protections, if any, were in place for him between March and May is not something the inspection report addresses. What the report makes clear is that the system designed to identify and protect residents like him was completed on paper and ignored in practice, and that two staff members, when shown the evidence, agreed.
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 2026-05-26 including all violations, facility responses, and corrective action plans.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 15, 2026 · Our methodology
El Paso Rehabilitation and Health Care Center in EL PASO, IL was cited for violations during a health inspection on May 26, 2026.
The form was explicit: check any of those boxes, and the resident is at risk.
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.