El Paso Rehab: Elopement Plan Failures After Two Escapes - IL
That finding sits at the center of a complaint inspection completed August 19, 2025, by state surveyors reviewing care practices at the facility. Inspectors identified one resident, referred to in the report as R1, whose elopement risk had been documented for months but whose care plan had not been revised even after two separate attempts to leave the building unattended within days of each other.
The first incident is recorded in nursing notes dated July 29, 2025. Staff noted R1 had left the building through the front door. The note describes it as a change in condition and says there were no further behaviors or attempts to exit after that. That assessment proved wrong within four days.
At 2:54 in the morning on August 1, a nursing assistant spotted R1 walking down a hallway toward the common room. A nurse watching on camera saw what was about to happen. Staff ran to the front door, but R1 was already through it and into the parking lot. According to the nursing notes, she continued walking forward, pushing past staff, past the stop sign, and down the street. She yelled throughout. When staff tried to intervene, she swung closed fists at them and repeatedly attempted to physically assault the people trying to bring her back inside. A physician was reached by phone and ordered her sent to a hospital for a psychiatric evaluation. Because facility staff could not get her safely back into the building on their own, police were also called.
R1's care plan had identified her as an elopement risk and wanderer since at least April. The interventions on file included offering pleasant diversions, monitoring for fatigue and weight loss, and calmly redirecting her while reminding her that the facility was her home. The most recent revision to that plan was dated May 27, 2025. Nothing was added after July 29. Nothing was added after August 1.
When a surveyor met with the facility's care plan coordinator on August 19, the coordinator confirmed the plan had not been revised following either elopement attempt. The coordinator said the management team should have reviewed the care plan after each incident and developed new interventions to reduce the risk of R1 leaving again.
That acknowledgment from inside the facility is the clearest part of the record. The care plan coordinator did not dispute what had happened or offer an explanation for why the review had not occurred. The facility had a policy directing staff to use assessment data to develop plans that help residents achieve the highest practical level of safety and wellbeing. After R1 walked out twice, one of them a pre-dawn confrontation that ended with police in the parking lot, no one revised the plan.
The inspection was classified as minimal harm or potential for actual harm, the lower end of the federal harm scale. The finding applied to one resident out of a sample of five reviewed for care planning during the complaint inspection.
R1 was transported to a local hospital after the August 1 incident. What the psychiatric evaluation found, and what happened to her afterward, is not recorded in the inspection report.
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.
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.
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: September 22, 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.
That finding sits at the center of a complaint inspection completed August 19, 2025, by state surveyors reviewing care practices at the facility.
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.