El Paso Rehab: Resident With Dementia Escapes Twice - IL
She told him they were gone. She went to grab her phone. When she came back to the door, he was already at the end of her driveway.
The man was a resident of El Paso Rehabilitation and Health Care Center, directly across the street. He has Alzheimer's disease with delusions and hallucinations, and schizophrenia with delusional disorder. His state-appointed guardian had told inspectors he did not have the mental capacity to be outside the facility unsupervised. His psychiatric nurse practitioner said the same thing. So did his family.
Nobody at the facility had ever formally identified him as an elopement risk.
The neighbor, identified in the inspection report only as V6, called the facility's main phone number first. Nobody answered. She then called a personal cell number she had for one of the nurses, who answered and ran to the door with a colleague. The resident was standing at the edge of the property. They walked him back inside.
That was the second time he had left the building unsupervised in six days.
The first incident happened May 10. A certified nursing assistant told inspectors she last saw the resident in the dining room that day. She did not document the incident in his electronic medical record. She said she didn't know how he got out.
By the time inspectors arrived the following week, staff had pieced together a theory for the May 16 incident: the resident had apparently followed a flower delivery person out the front door without anyone noticing.
His family described a man living inside a decades-old delusion. He has been in long-term care since the 1970s. He sits at the doors of the facility and waits for his wife and children to come pick him up and take him to the family farm. He has never been married. He has never had children. The farm was sold years ago. Both of his parents are dead.
The state guardian said she was never notified that he had left the facility unattended. The family said he is not capable of being in the community without supervision.
The licensed practical nurse who serves as the facility's care plan coordinator confirmed to inspectors that the resident's habit of sitting at the door and announcing he was leaving had never been added to his care plan. She acknowledged it should have been. The social service aide and the same nurse reviewed his elopement risk assessment together during the inspection and both confirmed he should have been flagged as a risk, and that interventions should have been put in place. None were.
Federal inspectors classified the violation at a level of minimal harm or potential for actual harm, affecting a small number of residents.
What the classification does not capture is the specific texture of what was missed. This was not a resident who wandered unpredictably. His behavior was known, named, and described in identical terms by nearly everyone who worked with him or cared about him. He sat at the front door. He said his family was coming. He talked about the farm. The psychiatric nurse practitioner knew it. The social service aide knew it. The family knew it. The neighbor across the street learned it within minutes of opening her door.
The facility knew it too. They just never wrote it down in a way that required anyone to act on it.
When the neighbor called the main number on May 16, the phone rang without an answer. She reached a nurse on a personal cell phone instead. That is how a man with Alzheimer's and schizophrenia, standing at the end of a stranger's driveway in a small Illinois town, got back inside.
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 17, 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.
When she came back to the door, he was already at the end of her driveway.
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.