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Complaint Investigation

El Paso Rehabilitation And Health Care Center

August 19, 2025 · El Paso, IL · 850 East Second Street
Citations 2
Beds 123
Provider ID 146097
Healthcare Facility
El Paso Rehabilitation And Health Care Center
El Paso, IL  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

El Paso Rehabilitation and Health Care Center in EL PASO, IL — inspection on August 19, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0580
Resident Rights Deficiencies

(injury/decline/room, etc.) that affect the resident.

return from the hospital for one of three residents (R1), reviewed for family notification, in a sample of

directs staff, To ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as: Transfer of the resident.

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.R1's electronic medical record documents R1 was transferred to the local emergency room on 8/1/25 at 3:12 A.M. after experiencing increased behaviors and delusions. R1'S Nursing Progress Notes, dated 8/1/25 document, 8/1/2025 (R1) back from hospital at approximately 10:30 A.M., yelling and agitated and crying out, refused vitals, did report that she will run again. On 8/18/25 at 10:35 A.M., Z10/R1's Family Member stated, I am (R1's) guardian due to her mental health.

They (facility staff) called me to tell me (R1) was running away and they had called the police and were having (R1) taken to the hospital.

But no one ever called me to tell me (R1) came back (to facility). It wasn't until I called them (facility) on (8/2/25) and asked them, did I know what had happened to (R1).

They (facility) are supposed to call me and let me know.On 8/19/25 at 1143 A.M., V1/Administrator verified that R1's mother (Z1) had not been called by facility staff to alert her that R1 had returned to the facility.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

146097 08/19/2025

El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738

reviewed, and revised by a team of health professionals.

repeated attempts, on two different days, to elope from the facility, for one of one resident (R1),

12/2024 directs staff, Purpose: To address each resident's strengths, weaknesses and care needs.

To use this assessment data to develop a comprehensive plan of care for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning and wellbeing as possible. R1's Nursing Progress Notes, dated 7/29/25 at 3:35 P.M. document, (R1 is experiencing a change in condition. (R1) left building through the front door.Resident has had no further behaviors or attempts to exit building.R1's Nursing Progress Notes, dated 8/1/25 at 2:54 A.M. document,(R1) was observed by CNA (Certified Nursing Assistant) walking down the hallway, and turning towards the common room. A few seconds after it was observed by nurse on camera that (R1) was attempting to exit the facility.

Writer, other nurse on floor, and (other staff) ran to front door as (R1) was observed walking out the door and into the parking lot. (R1) continued to walk forward and push past staff down the street and past the stop sign. (R1) continued to walk and push forward, while yelling throughout and became violent and combative swinging closed fists at nearby staff. (R1) repeatedly attempted to swing and physically assault staff. MD (Physician) was contacted and order received to send to hospital for psych (psychiatric) evaluation.

Police were also then contacted as the facility staff was unable to get (R1) safely back to building. (R1) transported to local hospital.R1's Care Plan, dated (revised) 5/27/25 includes the following Focus Area: (R1) is an elopement risk/wanderer.

This same plan of care includes the following Interventions: 4/10/25 Distract (R1) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. 5/1/25 Monitor for fatigue and weight loss. 5/27/25 Calmly redirect (R1) and remind her that this is her home.

Find a task, activity or simply a conversation to engage her in. No further interventions were implemented after R1's elopement from the facility on 7/29/25 or 8/1/25, were developed by the facility staff. On 8/19/25 at 1:10 P.M., V10/Care Plan Coordinator verified R1's care plan was not revised after R1's recent attempts on 7/29/25 or 8/1/25 to leave the facility unattended. At that time, V10 stated that the facility management team should have reviewed R1's plan of care after each elopement attempt and implemented new interventions to reduce the risk of R1 leaving the facility.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EL PASO, IL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from El Paso Rehabilitation and Health Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.