Cycle 1
Health 2025-12-08 · Fire 2025-12-08
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Indianapolis, IN
Arlington Place Health Campus
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1635 N Arlington Ave, Indianapolis, IN
(317) 353-6000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
64
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2014-03-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.09
CMS adjusted total nurse staffing hours
Case-mix index
1.66
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,618
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9965
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.46
Baseline 19.77% · Performance 18.44% · Measure score 6.46 · Achievement 6.46 · Improvement 4.36
Healthcare-associated infections
2.95
Baseline 5.56% · Performance 6.95% · Measure score 2.95 · Achievement 2.95 · Improvement 0
Total nurse turnover
7.93
Baseline 43.55% · Performance 31.25% · Measure score 7.93 · Achievement 7.93 · Improvement 6.08
Adjusted total nurse staffing
0.05
Baseline 2.74 hours · Performance 2.91 hours · Measure score 0.05 · Achievement 0 · Improvement 0.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.15% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 181 · Observed rate 18.78% · Lower 95% interval 10.37% |
| Discharge to community | 60.4% |
50.57%
9.8 pts better
|
Better than the National Rate · Eligible stays 170 · Observed rate 52.35% · Lower 95% interval 52.62% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 86 · Denominator 86 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 86 |
| Discharge self-care score | 50.67% |
53.69%
3 pts worse
|
Numerator 38 · Denominator 75 |
| Discharge mobility score | 53.33% |
50.94%
2.4 pts better
|
Numerator 40 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 86 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.95% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 7.14% · Lower 95% interval 4.06% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 92 |
| Staff flu vaccination coverage | 13.33% |
42%
28.7 pts worse
|
Numerator 18 · Denominator 135 |
| Discharge function score | 54.67% |
56.45%
1.8 pts worse
|
Numerator 41 · Denominator 75 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 98.41% |
96.28%
2.1 pts better
|
Numerator 62 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 48.89% |
25.2%
23.7 pts better
|
Numerator 22 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
93.6%
0.8 pts worse
|
93.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 88.6% · Q3 91.9% · Q4 94.1% · 4Q avg 92.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.2% |
95.4%
8.2 pts worse
|
95.5%
8.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.8%
1.6 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.9% · Q3 2.7% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.1% |
24.6%
21.5 pts better
|
11.4%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 0.0% · Q3 2.9% · Q4 3.1% · 4Q avg 3.1% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.6%
0.1 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.2% · Q3 3.0% · Q4 6.2% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.9% |
23.5%
19.6 pts better
|
19.6%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 0.0% · Q3 3.0% · Q4 6.2% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.4% |
14.8%
7.4 pts better
|
16.7%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 12.0% · Q3 8.0% · Q4 4.2% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.9% |
13.3%
4.4 pts better
|
16.3%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
11.7%
4.6 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 12.0% · Q4 4.5% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
24.2%
1.6 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 19.5% · Q3 27.3% · Q4 30.0% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
4.1%
3 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 2.7% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.7% |
81.6%
7.1 pts better
|
81.7%
7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.8% · Q2 81.2% · Q3 91.0% · Q4 93.7% · 4Q avg 88.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
10.5%
4.4 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 6.2% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 71.2% |
79.0%
7.8 pts worse
|
79.7%
8.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 71.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
22.4%
1.1 pts worse
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 23.8% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-21 · Fire 2024-10-21
4 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-07-25 · Fire 2023-07-25
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2026-01-22
F · Potential for more than minimal harm
2025-12-08
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2026-01-22
F · Potential for more than minimal harm
2024-10-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-10-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-10-21
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-11-11
E · Potential for more than minimal harm
2024-10-21
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2024-11-11
C · Minimal harm
2024-10-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-11
F · Potential for more than minimal harm
2023-07-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-07-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-07-25
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-07-25
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-07-25
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-07-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-08
E · Potential for more than minimal harm
2023-07-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-08
C · Minimal harm
2023-07-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-08
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-12-08
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-12-08
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-12-08
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-12-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-12-08
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-12-23
F · Potential for more than minimal harm
2024-10-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-21
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-08
E · Potential for more than minimal harm
2023-07-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-17
E · Potential for more than minimal harm
2023-07-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-25
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-07-25
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-05-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-05-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-06
G · Actual harm
2023-04-26
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-03-14
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-03-31
Penalties and ownership
What sits behind the stars
$0
2023-04-26
Payment Denial
Payment Denial · denial start 2023-05-20 · 18 days
18 day denial
Ownership
Witham Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Bardoczi, Stephen
Corporate Officer · Individual
Bayston, Brett
Corporate Director · Individual
Blackwell, Cory
Operational/Managerial Control · Individual
Brand, John
Corporate Director · Individual
Braverman, Kelly
Corporate Officer · Individual
Castetter, Andrea
Corporate Director · Individual
Hawkins, Claude
Corporate Director · Individual
Hornbecker, Michael
Corporate Director · Individual
Reagan, Julie
Corporate Director · Individual
Rhs Partners Of Arlington LLC
Operational/Managerial Control · Organization
Sellers, Daniel
Corporate Officer · Individual
Yassin Kassab, Mahmoud
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Miller's Merry Manor
Indianapolis, IN
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Community Nursing And Rehabilitation Center
Indianapolis, IN
2-star overall rating with 1-star inspections with Special Focus status with 24 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#3
Rosewalk Village
Indianapolis, IN
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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