Arcadia Care Aledo

In the surveyor’s words

From the most serious findings on record at Arcadia Care Aledo, in the surveyor’s own words.

• Immediate jeopardy, patternF600Dec 1, 2025

  Based on observation, interview and record review the facility failed to recognize an altercation between an employee and a resident as verbal abuse, failed to prevent access to all other facility residents by the same employee, resulting in this employee verbally abusing a second resident (R7) on a different occasion, failed to prevent resident to resident physical abuse for three of three residents (R2, R3 and R5) and failed to prevent employee to resident physical abuse (R8), for eight of eight residents reviewed for abuse, in a sample of 8.This failure has the potential to affect all 51 facility residents and resulted in R6 to feel fear, anxiety and shame.These failures resulted in an Immediate Jeopardy. […]

• Immediate jeopardy, isolatedF689Jan 31, 2022

  Based on observation, interview and record review, the facility failed to ensure facility exit door alarms were activated, failed to increase supervision/monitoring after recognizing an alert and oriented resident's change in mental status and failed to follow its policy for elopement prevention and door alarms for one of three residents (R1) reviewed for elopement in the sample of three. These failures resulted in R1 exiting from the facility on 1/15/22 around 6:45 P.M. after sunset, in freezing temperatures and snow covered grounds for approximately 45 minutes. R1 was found laying in the snow at the bottom of a hill in a residential yard approximately 30-40 feet from the facility. […]

• Actual harm, isolatedF689Feb 9, 2026

  Based on observation, interview and record review, the facility failed to ensure a resident was supervised in the dementia unit and away from the doors. This failure resulted in R1 being hit by the door for a second time, causing her to fall and fracture her hip. The facility failed to ensure a resident was safely transferred after a fall for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3.The findings include:R1s admission record documents she was admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. […]

• Actual harm, isolatedF550Dec 1, 2025

  Based on interview and record review, the facility failed to maintain a resident's right to be treated with dignity for (R6), one of eight residents reviewed for resident rights, in a sample of 8. This failure resulted in R6 to suffer shame and embarrassment. The (State) Long-Term Care Ombudsman Program Residents' Rights for People In Long-Term care Facilities, provided to all new residents upon admission to the facility documents, As an individual living in a long-term care facility, you retain the same rights as every citizen of (State) and of the United States. The following regulations provide clarity on specific rights granted to residents living in long-term care facilities. […]

• Actual harm, isolatedF607Dec 1, 2025

  Based on interview and record review, the facility failed to implement written policies and procedures for the investigation of allegations of abuse, including identification of abuse, failed in the protection of residents during investigations, and failed taking corrective actions for allegations of abuse, for two of eight residents reviewed for abuse (R6 and R7), in a sample of 8. These failures resulted in this same employee verbally abusing a second resident (R8) on a different occasion. The facility Abuse Prevention and Reporting policy, dated 09/2024 directs staff, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. […]