Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arlington Place Health Campus during CMS and state inspections, most recent first.
Food was not consistently held or served at proper temperatures. A resident reported meals were always served cold, and several residents waiting for lunch said hot food was served cold at every meal. In the kitchen, the DM checked prepared food and found smoked sausage at 123 degrees Fahrenheit, below the facility policy for hot holding and serving temperatures. Another resident said food temperature concerns were discussed at every resident council meeting.
Failure to complete self-medication assessments for two residents: one resident with depression and moderate cognitive impairment had a medication cup left at bedside and did not know what the pills were, and the DNS confirmed no self-medication assessment was in the chart. Another resident with diabetes was self-administering insulin and choosing the dose, but the record lacked a self-medication assessment, provider order, and care plan authorizing self-administration.
A facility failed to ensure the resident representative for a cognitively impaired resident was informed in advance of the risks and benefits of psychotropic medications. The resident had dementia, CKD, and severe protein-calorie malnutrition, and staff interviews confirmed the resident was confused and unable to understand medication side effects. Although an informed consent observation documented education to the resident, the DON and Clinical Support Nurse stated family education was needed for residents with low cognitive status, and the facility policy required consent and education of the Resident/Responsible party for ordered psychotropic meds.
Failure to Notify Resident Representative of Significant Weight Loss: A resident with dementia, CKD, and severe protein-calorie malnutrition was severely cognitively impaired and experienced an 11% weight loss after admission. The clinical record had no documentation that the resident's representative was notified, and the DON and Clinical Support Nurse stated the family should have been informed of the significant weight loss.
A resident with hyperlipidemia, obesity, and acute respiratory failure was found unresponsive and sent to the hospital, but the record did not show that the bed hold policy was given to the resident or the representative at discharge. The discharge form also did not indicate whether the policy was provided, despite facility policy requiring written notice of bed hold and admission policies when a resident goes to the hospital.
PASARR Not Updated After Mental Health Diagnoses and Psychotropic Medications Were Added: Two residents had PASARR Level I screenings that did not reflect later-added depression diagnoses and antidepressant medications. One resident’s record later included depression, dementia, Alzheimer’s disease, anxiety, and orders for escitalopram and bupropion, while another resident’s record later showed depression and fluoxetine, but the PASARR remained inaccurate and did not list the diagnosis or medication.
Medication carts had loose pills and powdered debris in multiple drawers, and narcotic packaging was found compromised and taped in the narcotic box. Controlled-drug records showed a QMA administered PRN meds without documented nurse approval or signature, and one alprazolam label did not match the physician order. Staff interviews confirmed inconsistent documentation of nurse authorization for PRN meds.
Missing Enhanced Barrier Precaution Signs: Enhanced barrier precaution signs were not posted for three residents who had orders for devices requiring those precautions. One resident had a wound vac and diagnoses including type 1 DM, gas gangrene, and a chronic heel ulcer; another had a PICC line with chronic lung disease, respiratory failure, and a hx of stroke; and a third had a catheter with chronic lung disease, inflammatory bowel disease, and hypothyroidism. The IP stated the signs should have been posted but were missing.
Inaccurate COVID Vaccine Consent Documentation: The facility failed to document consent accurately before giving a COVID vaccine to a resident with severe cognitive impairment and multiple diagnoses, including dementia and anoxic brain damage. Records showed a prior refusal and a later unsigned consent form, yet the Moderna vaccine was still administered. The resident's representative said she was not aware of the vaccine being given and had not received written education beforehand. The IP said paper forms were used to keep up with flu and COVID vaccinations, and the DON stated consent was required before vaccination.
The facility failed to ensure dietary staff with facial hair wore beard coverings, as observed during a kitchen inspection. A staff member was seen preparing lunch without a beard covering, contrary to the facility's policy requiring facial hair restraints in food production areas. This deficiency could potentially affect all 42 residents receiving food prepared in the kitchen.
The facility failed to maintain infection control during medication administration for three residents, as an LPN did not perform hand hygiene at critical points. Additionally, a CRCA did not follow enhanced barrier precautions for a resident with a feeding tube, failing to wear a gown during high-contact care, despite facility policy and signage indicating the requirement.
A resident was transferred to a hospital due to a medical condition, but the facility failed to inform him and the State Ombudsman of a subsequent discharge due to payment issues. The resident was unaware of the discharge until his belongings were brought to the hospital. The facility did not adhere to its policy requiring a 30-day notice for non-emergency discharges, leading to a deficiency.
The facility failed to monitor urinary output and symptoms of urinary tract infections for two residents with catheters. Resident C had inconsistent documentation of urinary output and delayed follow-up after blood was noted in urine, leading to hospital discharge for a UTI. Resident E's records lacked documentation of catheter care and urinary output after returning from a hospital stay. Staff interviews confirmed that output should be measured in milliliters, but this was not consistently done, violating the facility's catheter care procedures.
Food Served at Improper Temperatures
Penalty
Summary
The facility failed to ensure food temperatures were at an appetizing temperature and kept at safe holding temperatures. A resident reported that breakfast, lunch, and dinner meals were always served cold, and during a dining observation, residents waiting for lunch stated that food that was supposed to be hot was served cold at every meal in the dining room. In the main kitchen, the Dietary Manager used a thermometer to check prepared food and found smoked sausage at 123 degrees Fahrenheit, stating it needed to be reheated; he also stated he preferred all food to be held at 150 degrees Fahrenheit, while the facility policy indicated hot food in the steam table should be at least 135 degrees Fahrenheit and arrive at greater than or equal to 120 degrees Fahrenheit when served. Another resident stated resident council discussed food temperature concerns at every meeting and that food that was supposed to be hot was normally served cold.
Failure to Complete Self-Medication Assessments
Penalty
Summary
The facility failed to timely complete self-medication assessments for two residents who were receiving medications in ways that required evaluation and documentation. One resident with depression and moderate cognitive impairment was observed sitting in bed with a medication cup containing four pills on the bedside table, and the resident stated the nurse had left the medication for him to take. The resident did not know what the medications were. The LPN who was interviewed was unsure whether a self-medication assessment had been completed, and the DNS later confirmed that no self-medication assessment was in the resident’s clinical record. A second resident with diabetes mellitus was receiving lispro insulin by sliding scale, scheduled lispro insulin three times daily, and lantus insulin with breakfast. The May 2026 MAR/TAR showed the resident self-administered insulin on multiple dates, and the DNS stated the resident chose the dosage amount and self-administered her insulin medications, with the medical provider aware. However, the clinical record did not include a self-medication assessment, medical provider orders authorizing self-medication, or a care plan indicating the resident was able to self-medicate her insulin. The facility policy provided by the DNS stated residents requesting to self-medicate or with self-medication in the plan of care are to be assessed and the assessment documented in the EHR.
Failure to Inform Resident Representative of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure the resident representative for a cognitively impaired resident was informed in advance of the risks and benefits of medications for Resident 3. Resident 3 had diagnoses including dementia, chronic kidney disease, and severe protein-calorie malnutrition, and an MDS assessment dated 10/10/25 indicated the resident was severely cognitively impaired. Physician orders included olanzapine 2.5 mg twice daily from 10/4/25 to 10/8/25 and trazodone 25 mg at bedtime for insomnia starting 10/7/25. A facility psychotropic medication informed consent observation dated 10/8/25 indicated Resident 3 was educated on the risks, benefits, alternative treatment options, and applicable black box warnings. During interviews, CNA 8 and LPN 7 stated Resident 3 was confused and would not be able to understand the side effects of medications. The DON stated Resident 3 had impaired cognition and staff would need to educate the family to obtain informed consent, and Clinical Support Nurse 1 stated staff should educate families to obtain informed consent for residents with low cognitive status. The facility policy titled Psychotropic medication use and gradual dose reduction guidelines stated consent shall be obtained upon admission for ordered psychotropic medications to ensure the Resident/Responsible party is educated on the risks, benefits, alternative treatment options, and applicable black box warnings.
Failure to Notify Resident Representative of Significant Weight Loss
Penalty
Summary
The facility failed to ensure the resident representative for a cognitively impaired resident was notified of a significant weight loss. Resident 3 had diagnoses including dementia, chronic kidney disease, and severe protein-calorie malnutrition, and an MDS assessment dated 10/10/25 indicated the resident was severely cognitively impaired. The clinical record showed the resident weighed 149 pounds on admission on 10/4/25, then 131.8 pounds on 11/14/25 and 130.3 pounds on 11/18/25, reflecting an 11% weight loss from admission to 11/14/25. There was no documentation in the clinical record showing that the resident's representative was notified of the significant weight loss. During interviews, the DON stated the family would need notification because the resident had impaired cognition, and Clinical Support Nurse 1 stated staff would need to notify the family of a significant weight loss. The facility policy on Notification of Change in Condition stated the facility must inform the resident, consult with the resident's physician, and if known notify the resident's legal representative when there is a significant change in physical, mental, or psychosocial status, and that documentation of notification or notification attempts should be recorded in the electronic health record.
Failure to Provide Bed Hold Policy at Hospital Transfer
Penalty
Summary
The facility failed to ensure that a bed hold policy was provided to Resident 81 and the resident's representative at the time of discharge after the resident was sent to the hospital. Resident 81 had diagnoses including hyperlipidemia, obesity, and acute respiratory failure. A nursing progress note documented that the resident was found unresponsive and staff called 911, after which the resident was transported to the hospital. The clinical record contained no documentation that the bed hold policy was provided to the resident or the resident's representative, and the clinical discharge observation form did not indicate whether the policy had been provided. During interview, Clinical Support 1 stated that staff should provide the bed hold policy to the resident and representative at the time of discharge. The facility policy stated that residents and responsible parties have a right to be notified verbally and in writing of the reserve bed payment policy when someone goes out to the hospital, and that written information on bed hold and admission policies should be provided before transferring a resident to a hospital or allowing therapeutic leave.
PASARR Not Updated After Mental Health Diagnoses and Psychotropic Medications Were Added
Penalty
Summary
The facility failed to ensure Preadmission Screening and Resident Review (PASARR) was completed after changes in mental health status and psychotropic medication use for two residents. One resident had a PASARR Level I screening that stated no mental health medications and no mental health or dementia diagnoses were present, but later the clinical record showed diagnoses including major depressive disorder and dementia without behavioral disturbance, along with orders for escitalopram and bupropion for depression. A physician progress note also documented the resident was being followed for Alzheimer’s disease, depression, and anxiety, and the care plan identified risk for adverse effects from antidepressant use and noted depression. A second resident had a PASARR Level I screening indicating no suspected mental illness, intellectual disability, related condition, or mental health medications, but the clinical record later showed a diagnosis of depression and an order for fluoxetine 20 mg daily for depression. The PASARR did not list the fluoxetine or the diagnosis of depression. Staff interviews indicated the MDS support nurse expected a new PASARR when a new diagnosis or psychotropic medication was added, and the Social Services Director stated he had not realized the PASARR lacked diagnoses or new medications.
Medication carts contained loose pills, damaged narcotic packaging, and incomplete PRN controlled-drug documentation
Penalty
Summary
Medication carts were found with loose pills and powdered debris in multiple drawers, and one cart contained a loose half tablet. On the 100-hall medication cart, drawer 2 had two loose pills and powdered debris, and the narcotic box contained oxycodone 5 mg 1/2 tablet packs, including one pack with a compromised pocket secured with clear tape and the tablet still present in the package. Another oxycodone 5 mg 1/2 tablet pack in the same narcotic box had pockets 11 and 12 taped, with the tablets no longer present in the package. Controlled drug use records also showed PRN medications being administered by a QMA without a nurse signature or documented nurse approval. One oxycodone/acetaminophen 5-325 mg record had 3 of 6 administrations without nurse approval documented, another oxycodone/acetaminophen 5-325 mg record had 1 of 1 administration without nurse approval documented, and an alprazolam record had 4 of 4 administrations by a QMA without nurse signature or documented nurse approval. The alprazolam pharmacy label also did not match the physician’s order in the clinical record, which listed a different strength and directions. The 200-hall medication carts were also observed with loose pills and powdered debris in multiple drawers. One cart had loose pills and debris in drawers 1 through 4, and another cart had a loose half pill in drawer 1 and powdered debris in drawers 2 and 3. Staff interviews indicated nurses were responsible for checking carts for loose pills, damaged packaging, and cleanliness, but the DON stated QMAs were not consistent with documenting nurse approval for PRN medications. The facility policies stated medications must be stored properly, damaged or deteriorated medications removed from inventory, labels must match the order, and PRN medication administered by a QMA required authorization from a licensed nurse.
Missing Enhanced Barrier Precaution Signs
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because enhanced barrier precaution signs were not posted for three residents who had orders for devices requiring those precautions. Resident 5 had a wound vacuum and diagnoses including type 1 diabetes, gas gangrene, and a chronic ulcer of the left heel, but no enhanced barrier precaution sign was posted in or on the outside of the room during multiple observations. The clinical record showed a physician's order for the wound vacuum, but no physician's order for enhanced barrier precautions was located at the time of record review. Resident 86 had a PICC line and diagnoses including chronic lung disease, respiratory failure, and a history of stroke, yet no enhanced barrier precaution sign was posted in or on the outside of the room during multiple observations. Resident 87 had a catheter and diagnoses including chronic lung disease, inflammatory bowel disease, and hypothyroidism, and no enhanced barrier precaution sign was posted in or on the outside of the room during observations. During interview, the Infection Preventionist stated the residents should have had enhanced barrier precaution signs and that the signs were missing and not posted.
Inaccurate COVID Vaccine Consent Documentation
Penalty
Summary
The facility failed to ensure consents were documented accurately before administering a COVID-19 vaccine for one resident. Resident 51 had diagnoses including acute cystitis without hematuria, anoxic brain damage, elevated white blood cell count, pulmonary fibrosis, dementia, type 2 diabetes mellitus with hyperglycemia, diabetic chronic kidney disease, and aphasia. A BIMS assessment dated 11/6/25 showed severe cognitive impairment. The record included a COVID vaccination consent form dated 1/11/24 stating the resident's representative refused the COVID vaccination, and another consent form dated 11/5/25 indicating the representative had not signed consent for the resident to receive the vaccine. Despite the unsigned consent form, the Moderna COVID vaccine was documented as given on 11/7/25 in the left arm, and a physician's order dated 11/7/25 directed monitoring for side effects three times a day until 11/9/25. The resident's representative stated she did not remember any discussion about the resident getting a COVID vaccine, found a band-aid on his arm during a visit, was told he received a shot, and was unaware of what shot he had received; she also stated she never received written education on the COVID vaccination prior to administration. The IP stated she had used paper forms instead of computerized consents to keep up with the large number of residents needing flu and COVID shots, and the DON stated consents were required prior to giving a vaccine and the IP must have missed checking the yes box when the representative was there.
Failure to Ensure Beard Coverings in Kitchen
Penalty
Summary
The facility failed to ensure that dietary staff with facial hair wore beard coverings, as observed during a kitchen inspection. On October 15, 2024, at 11:44 a.m., a staff member with facial hair on his lip and chin was seen preparing lunch without a beard covering. This observation was made during a tour of the kitchen with the Director of Food Services. During an interview conducted shortly after, the Director confirmed that the staff member should have been wearing a beard covering. The facility's policy, provided by the Administrator on October 17, 2024, mandates that beard and mustache hair must be covered in kitchen food product areas, and facial hair restraints are required in any production area. This deficiency has the potential to affect all 42 residents receiving food prepared in the kitchen.
Infection Control Deficiencies in Medication Administration and Barrier Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for three out of four residents observed. An LPN was observed preparing and administering medications without performing hand hygiene at critical points. For Resident 31, the LPN touched various items and unwrapped a straw with bare hands before administering medication, without washing hands prior to the administration. For Resident 9, the LPN picked up a dropped pill from the floor with bare hands, donned gloves without hand hygiene, and continued medication preparation and administration without washing hands at necessary intervals. Similarly, for Resident 91, the LPN did not perform hand hygiene before donning gloves to administer insulin. Additionally, the facility did not adhere to enhanced barrier precautions for a resident requiring such measures. Resident 2, who had a feeding tube and required enhanced barrier precautions during high-contact care, was not provided care in accordance with these precautions. A CRCA was observed providing care without wearing a gown, despite the presence of a sign indicating the need for enhanced barrier precautions and available gowns in the room. The facility's policy required the use of gowns and gloves during high-contact care activities, which was not followed in this instance.
Failure to Inform Resident and Ombudsman of Discharge Due to Payment Issues
Penalty
Summary
The facility failed to properly inform a resident and the State Ombudsman Agency about a facility-initiated discharge due to payment coverage issues. Resident C, who had been residing in the facility with diagnoses including pressure ulcers, was transferred to an acute care hospital due to a change in medical condition. The facility issued a Notice of Transfer or Discharge on the day of the transfer, citing the need to meet the resident's welfare as the reason. However, there was no documentation of a subsequent notice regarding the discharge due to non-payment or insurance coverage issues. Interviews revealed that Resident C was unaware of the discharge until the facility's Administrator and Director of Nursing brought his belongings to the hospital and informed him of the discharge. The State Ombudsman was also not informed of the discharge until after the fact. The facility's policy requires a 30-day notice for non-emergency discharges, which was not adhered to in this case. The facility's Bed Hold Policy was also not properly communicated to Resident C, who was a private pay resident at the time of discharge. The facility's failure to provide timely and adequate notice of the discharge, as well as the lack of documentation and communication regarding the insurance coverage issue, led to the deficiency. The facility's actions were not in compliance with federal regulations that require proper notification and documentation for resident transfers and discharges.
Failure to Monitor Urinary Output and Symptoms in Residents with Catheters
Penalty
Summary
The facility failed to accurately monitor urinary output and symptoms of urinary tract infections for residents with urinary catheters, specifically for Resident C and Resident E. Resident C had a urinary catheter due to a neurogenic bladder and a stage 4 wound, with a care plan in place to monitor for complications such as urinary tract infections and to record urinary output. Despite a physician's order to monitor output every shift, the clinical record showed inconsistent documentation of urinary output, with vague terms like 'medium' and 'large' used instead of precise measurements. Additionally, after blood was noted in Resident C's urine, there was a lack of follow-up documentation until two days later when a nurse practitioner ordered a urinalysis, and Resident C was subsequently discharged to a hospital for a urinary tract infection. Resident E, who also had a neurogenic bladder and an indwelling urinary catheter, had a similar care plan to monitor urinary output and observe for complications. However, the facility's records showed that after Resident E returned from a hospital stay, there was no documentation of catheter care or urinary output for several days. Interviews with facility staff confirmed that urinary output should be measured in milliliters each shift, but this was not consistently done, as evidenced by the lack of documentation in the Treatment Administration Record (TAR). The facility's failure to maintain accurate records and monitor urinary output and symptoms of urinary tract infections for residents with catheters was further highlighted by the facility's own Suprapubic Catheter Care Standard Operating Procedure. This procedure outlined the need to observe urine levels, check for unusual appearances, and maintain accurate records of daily output, which were not adhered to in the cases of Resident C and Resident E. The deficiency was related to a complaint investigation, indicating a systemic issue in the facility's catheter care practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Miller's Merry Manor | 0.1 mi | ★★★★★ | 0 | 0 |
| Community Nursing And Rehabilitation Center | 0.5 mi | ★★★★★ | 17 | 0 |
| Rosewalk Village | 1.1 mi | ★★★★★ | 10 | 1 |
| Brickyard Healthcare - Brookview Care Center | 1.3 mi | ★★★★★ | 11 | 1 |
| Wildwood Healthcare Center | 1.3 mi | ★★★★★ | 9 | 0 |
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