Arcadia Care Aledo
ARCADIA CARE ALEDO in ALEDO, IL — inspection on December 1, 2025.
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
V6/Registered Nurse (RN) to assist her on the bedpan as she had to urinate.
States V6/RN told R6 all staff were busy assisting other residents. R6 states V6 swore at R6 and told her she would get someone to help R6 when they could. V7/LPN states that R6 told her a couple of hours later, no staff had responded to assist her on the bedpan and R6 was finally able to get herself closer to her bedside stand, grab an emesis basis, place it under herself and pee. V7 states R6 was very upset about having to use the emesis basin, that it hurt to use the emesis basin and not a bedpan and that R6 stated she was humiliated due to using the emesis basin to urinate in. At that time, V7/LPN states R6 told her she did not want V6/RN to ever take care of her again.On 11/25/25 at 1:05 P.M., V1/Administrator In Training stated V6/Registered Nurse should have assisted R6 to the toilet when she requested, and she considers R6 being forced to urinate in an emesis basin as unacceptable and a violation of R6's resident's rights.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/01/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Aledo
304 S.W. 12th Street Aledo, IL 61231
SUMMARY STATEMENT OF DEFICIENCIES
jeopardy to resident health or safety
11/23/25 documents, Physical Abuse, employee to resident. On 11/23/25 at approximately 5;30 P.M., R8 reported that agency staff (V10/Certified Nursing Assistant/CNA) was rough with cares. V10/CNA immediately suspended. R8 assessed immediately.
Appropriate notifications made.On 11/24/25 at 11:17 A.M., R8 was alert, oriented, and seated in an easy chair in her room, reading her bible. R8 was able to recall the incident of 11/23/25. R8 states the tall, black man that took care of me yesterday (11/23/25) was rough with me and hurt my wrist during cares.
States she was sitting in her chair in her room, reading her bible when V10/Agency CNA entered the room, roughly took her bible out of her lap and grabbed her right wrist and pulled on it, telling her she was wet (incontinent) and needed to get up and go to the bathroom.
R8 states she told V10 she would as soon as she finished the passage she was reading, but V10 was insistent and kept pulling on her wrist. R8 states she told V10 he hurt her and to leave her alone. R8 states her wrist feels okay now but was painful yesterday.The facility form, Staff Statement, dated 11/23/25 and signed by V11/Certified Nursing Assistant documents, While in the dining room passing medications this nurse overheard (R8) telling her table (mates) at supper that the male CNA hurt her wrist. As I approached (R8) she stated that she did not want that male CNA take care of her again, he hurt her wrist. (R8) states (V10) came in her room, grabbed her bible out of her hands and told her to get up and go to the bathroom and he grabbed her wrist and hurt it. No injuries noted. V2/Director of Nurses and V1/Administrator notified.
On 12/1/25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy:1.
All residents with a BIMS 12 and greater currently in-house had abuse interview completed to ensure no other residents had been harmed and they feel safe in the facility completed by V24/Dietary Manager by 11/26/25.2.
All residents with a BIMS 11 and below and skin assessments completed to ensure no other residents had been harmed and they feel safe in the facility completed by V2/Director of Nurses and V17/Wound Nurse by 11/26/25.3.
Family members/POAs of those residents with a BIMS of 11 and below currently in-house had abuse interviews completed to ensure no other residents had been harmed and they feel that their loved one is safe in the facility.
Initiated by V22/Business Office Manager on 11.26.25. 38 of these families answered the phone and were interviewed.
A message to return the phone call has been completed with the remaining 13 families.
Facility will continue to make daily calls until 100% compliance.
Administrator to monitor for compliance. 4.
All residents currently in-house had an abuse/neglect screening completed with care plans updated to reflect level of at risk for abuse as indicated.
Completed by V23/Social Services Director on 11/26/25.5.
Abuse in-servicing for all staff.
Completed by V1/Administrator in Training and V2/Director of Nursing, on 11.26.25.
Abuse Training will remain ongoing with all new hires, all agency staff, and current staff.
All staff in serviced before their next scheduled shift. 6.
Facility Administrator or Designee will interview 5 residents per week for 12 weeks to ensure residents feel safe and have no concerns with abuse.
Facility will utilize the abuse Allegation Interview questions for residents.
Completed on 11/26/25 by V1/Administrator in Training.7.
Facility Administrator or Designee will interview 5 staff members per week x 12 weeks to ensure staff know reporting requirements.
Facility will utilize an audit tool related to Abuse/Abuse Reporting/Abuse investigation.
Facility Administrator or designee will monitor for completion.
Completed by V1/Administrator in Training on 11/26/25.8.
Administrator In Training in-serviced on abuse by V12/Regional Nursing Consultant on 11/26/25.9.
All residents have the potential to be affected by V6(RN) alleged abuse. V6 (RN) is no longer employed as of 11/12/25.10. R6 had the potential to be affected by V6 (RN) alleged abuse. R6 discharged on 10/8/25.
Psych services are available to all residents by Psychiatric vendor.
Completion date 11/26/25
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/01/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Aledo
304 S.W. 12th Street Aledo, IL 61231
SUMMARY STATEMENT OF DEFICIENCIES
Based on the results of the investigation the facility has found the following: IDT (Intradisciplinary Team) met to discuss the investigation.
Also discussed appropriate interventions for resident.
Care plan reviewed and updated accordingly. SSD (Social Services Director) will follow up with resident for any psychosocial needs that arise.R7's Abuse Allegation Interview, dated as 11/12/25 and signed by V1/Administrator In Training documents, Can you tell me what happened? I needed to pee. so I didn't wet myself. (V6/RN) yelled at me and pushed me in my wheelchair down the hall.
What was said? (V6/RN) was cussing and saying I already went.The facility form, Staff Statement, dated 11/12/25 and signed by V8/Certified Nursing Assistant/CNA documents, I was in (another resident's room) with (V9/CNA). V6/RN was shouting at (R7) because he needed to use the bathroom. V6 then pushed R7 down the long hall and said, 'See all these call lights' and told R7 he needed to wait and let R7 down the hall.
During V6's shouting, V6 mentioned the F word, saying, 'FXXX this' and 'You need to FXXX wait.'On 11/25/25 at 11:54 A,M, V2/Director of Nurses stated the 11/12/25 incident between V6/RN and R7 was also investigated by herself and V1/Administrator. V2/DON states she would consider the incident to be verbal abuse as the resident and two different staff members over heard V6/RN cussing and yelling at R7 V2 states V12, V13 and V14 (Corporate Staff) made the decision to call the incident Misconduct: Unsatisfactory job performance and place V6 on a ‘Final Warning.' V2 states when she and V1 called R6 to discuss the incident and advise her of the final warning and tell V6 to return to work on November 21, 2025, V6 stated she was terminating her employment with the facility. On 11/25/25 at 1:05 P.M., V1/Administrator In Training stated there was a second incident on 11/12/25 involving V6/Registered Nurse and R7 where V6 was overheard cussing and yelling at R7 when R7 requested to use the bathroom while in the facility dining room as he didn't want to urinate on himself. V1 states during her investigation it was determined that V6 refused to provide toileting assistance for R7, pushed R7's wheelchair out of the dining room and down the hall, opposite direction from his room and placed him outside of another resident's room where V8 and V9/CNAS were providing care to another resident. V1 stated the incident was discussed with corporate staff (V12, V13 and V14) and the decision was made, at the Corporate level, to call the incident, ‘Misconduct' and to place V6/RN on a final warning.
When V6 was called on 11/20/25 and informed of the decision to place her on a final warning status and to inform V6 to return to work on 11/21/25, V6 chose to terminate her employment with the facility. V1/Administrator also stated she would consider the incident to be verbal abuse, and no changes were made to prevent future occurrences of abuse.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/01/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Arcadia Care Aledo
304 S.W. 12th Street Aledo, IL 61231
SUMMARY STATEMENT OF DEFICIENCIES
sitting in the hallway.
States he did not hear the nurse ask any staff to assist him and when the CNAs did assist him, he had urinated on himself.
States he was humiliated by the situation and doesn't want (V6/RN) to come near him any longer.On 11/25/25 at 1:05 P.M., V1/Administrator In Training stated there was a second incident on 11/12/25 involving V6/Registered Nurse and R7 when R7 requested to use the bathroom while in the facility dining room as he didn't want to urinate on himself. V1 states during her investigation it was determined that V6 refused to provide toileting assistance for R7, pushed R7's wheelchair out of the dining room and down the hall, opposite direction from his room and placed him outside of another resident's room where V8 and V9/CNAS were providing care to another resident. At that time, V1 verified that V6/RN should have assisted R7 with his toileting needs.
Facility ID: