El Paso Rehabilitation And Health Care Center
El Paso Rehabilitation and Health Care Center in EL PASO, IL — inspection on May 26, 2026.
Found 4 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
(injury/decline/room, etc.) that affect the resident.
of a cognitively impaired resident for one of three residents (R1) reviewed for notification in a sample
approved 12/2014, documents to ensure that the resident's family and or representative and medical practitioner are notified of resident changes, such as those listed below: an accident or incident, with or without injury that has the potential for needed medical practitioner interventions. A significant change in the resident's physical, mental, or psychosocial status.
This form documents an incident of wandering or elopement.
The facility's Past Noncompliance Statement, dated 5/10/26, documents that staff became aware that R1 had exited the building, without signing out or staff directly observing his departure through a secured exit.
The staff were unsure as to how this had occurred, as the doors to the facility are magnetically locked and require a code to disengage the system to exit the facility. R1's Progress Notes does not contain documentation that V18, State Guardian, was notified of R1's elopement from the facility on 5/10/26. On On 5/18/26 at 8:40am, V18, State Guardian, stated that she was not notified of R1 leaving the facility unsupervised. On 5/20/26 at 10:30am, V1, Administrator, stated that V18 was not notified of R1's leaving the facility until he did on 5/20/26.
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 05/26/2026
El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738
reviewed for accuracy of assessments in a sample of three.
Findings include:The facility's Elopement
that put them at risk for elopement.
All residents so identified will have these issues addressed in their individual care plans.
The facility's Care Planning policy, approved 12/2024, documents that every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. R1's current care plan or MDS does not address R1's exit-seeking behaviors.R1's Elopement Risk Assessment, dated 3/5/26, documents a. Is the resident cognitively impaired and independently mobile (with or without a device)? Yes is checked.
History of elopement. b1.
Does the resident have a history of elopement, 2. a desire to leave the building? 3. exit seeking with a purpose. 4. wandering activity. ba. If any of the above are checked, the resident is at risk for elopement.
Proceed with elopement interventions and elopement risk care plan.On 5/19/26 at 10:55am, V17, Social Service Aide, stated that she does the elopement risk assessments. V17 stated that R1 has a diagnosis of Alzheimer's and Psychosis. V17 also stated that R1 has a history of delusions, hallucinations, and fixates on the family farm from the past. V17 also stated that R1 states that his family is coming to pick him up to take him to the farm. V17 and V4, Licensed Practical Nurse/Care Plan Coordinator, both verified that after reviewing the elopement risk assessment, R1 should have been triggered as an elopement risk, and interventions should have been put into place, but were not.
146097 05/26/2026
El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738
actions that can be measured.
interventions to prevent an elopement of a cognitively impaired resident for one of three residents
approved 12/2024, documents every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual.
This form documents that the purpose is to assess 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 well-being as possible. R1's Care Plan, dated 5/15/26, does not contain goals or interventions for exit-seeking or elopement risk behaviors. On 5/15/16 at 3:30pm, R1 sat up on the side of his bed and stated that he was waiting for his mom, dad, and brother to come pick him up to take him to the farm. R1 was unable to give any specific information concerning leaving the day he left the building. On 5/16/26 at 11:45am, R1 was sitting on the side of his bed, stated that he is waiting for his mom and dad to come pick him up, to go to the farm. At 1:30pm, R1 was sitting in a chair at the front door, stating he was waiting for the tractors to go by.On 5/18/26 at 12:35, R1 stated that he just got a loan for 4 million dollars so he and four of his neighbors can start a dairy farm. R1 stated that it wall make 1,4 million dollars a year. At 12:55pm, R1 was sitting in a chair at the front door and stated that he was waiting for his family to come pick him up. At pm, 1:55pm, R1 remained in the same chair, waiting for his family. On 5/19/26 at 1:45pm-3:00pm, R1 sat in a chair by the front door. R1 stated that his family is coming to pick him up. On 5/16/26 at 11:00am, V4, Licensed Practical Nurse/Care Plan Coordinator, stated that R1 has a long history of sitting by the front doors waiting for his family to pick him up to take him to the farm. V4 also stated R1's behaviors of sitting at the door on a daily basis and talking about visiting his friends in the neighborhood should have been care planned.
146097 05/26/2026
El Paso Rehabilitation and Health Care Center 850 East Second Street El Paso, IL 61738
the last time she saw R1 on 5/10/26 was in the dining room. V22 verified that R1 has a history of
unsupervised. V22 stated that it is unknown how R1 got out of the building.
On 5/16/26 at 12:50pm, V5 stated that she received a call on her personal phone from an old employee, so she answered it. V5 stated that it was V6, Neighbor, telling her that a resident (R1) was on her porch and rang the doorbell. V5 stated that she and V4 ran to the door, and R1 was standing at the edge of the property. V5 stated that R1 was assisted back into the facility. V5 stated that it is assumed that R1 followed a flower delivery person out the door unnoticed. V5 also stated that R1 has a long history of sitting at the doors, waiting for his family to come pick him up and take him to the family farm.
On 5/18/26 at 8:40am, V18, State Guardian, stated that R1 did not have the mental capacity to be outside of the facility unsupervised. V18 also stated that R1 has a diagnosis of Schizophrenia with delusional disorder and Alzheimer's, so he should not be out unsupervised at all. V18 stated that R1 is very confused and always talking about leaving the facility, to go to his friend's house a couple of blocks away, or to the family farm. V18 stated that she was not notified of R1 leaving the facility unattended.
On 5/18/26 at 11:00am, V4, Licensed Practical Nurse/Care Plan Coordinator, stated that no one is allowed to leave the facility unsupervised. V4 stated that if a resident is leaving with their family, or the staff has to sign them out before leaving. V4 also verified that R1's behavior, sitting at the door and stating that he is leaving with his family, was not care planned and should have been.
On 5/18/26 at 12:30pm, V13, R1's Family, stated that R1 is not capable of being out in the community without supervision. V13 stated that R1 has been in a long-term care setting since the 1970's. V13 also stated that the R1 sits at the door waiting for his wife and children to come pick him up, but he has never been married or had children. V13 also stated that R1 thinks that the family still owns the farm, but it was sold many years ago. V13 stated that both of R1's parents have passed away.
On 5/18/26 at 1:05pm, V6, Neighbor, stated that her doorbell rang at 12:06pm, when she answered the door, there was an elderly man with a walker on her porch. V6 stated that he started to ask her about the family that used to live there, she told him that they no longer live there, and he needed to go back across the street. V6 stated that she went to grab her phone, and when she went back to the door, R1 was already at the end of her driveway. V6 stated that she called the facility phone number, and there was no answer, so she called V5's personal number. V6 stated that V5 answered, so she told her that R1 was outside, unsupervised.
On 5/18/26 at 1:55pm, V12, Psychiatric Nurse Practitioner, stated that R1 has a diagnosis of Alzheimer's with delusions and hallucinations, so he is not safe to be out in the community unsupervised.
On 5/19/26 at 10:55am, V17, Social Service Aide, stated that R1 has a diagnosis of Alzheimer's and Psychosis. V17 also stated that R1 has a history of delusions, hallucinations, and fixates on the family farm from the past. V17 also stated that R1 states that his family is coming to pick him up to take him to the farm. V17 and V4 both verified that after reviewing the elopement risk assessment, R1 should have been triggered as an elopement risk, and interventions should have been put into place, but were not.
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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.