Cycle 1
Health 2025-05-12 · Fire 2025-05-12
14 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fishers, IN
Hamilton Trace Of Fishers
3-star overall rating with 2-star inspections with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
11851 Cumberland Rd, Fishers, IN
(317) 813-4444
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cardon & Associates
Operator or chain grouping
Approved since
2011-10-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 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
0.76
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.70
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,179
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.12
Composite VBP score used to determine payment impact.
Payment multiplier
0.9904
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.39
Baseline 20.29% · Performance 20.79% · Measure score 1.39 · Achievement 1.39 · Improvement 0
Healthcare-associated infections
8.88
Baseline 4.78% · Performance 5.18% · Measure score 8.88 · Achievement 8.88 · Improvement 0
Total nurse turnover
3.15
Baseline 48.36% · Performance 50.79% · Measure score 3.15 · Achievement 3.15 · Improvement 0
Adjusted total nurse staffing
1.43
Baseline 3.78 hours · Performance 3.48 hours · Measure score 1.43 · Achievement 1.43 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.07% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 452 · Observed rate 13.27% · Lower 95% interval 10.4% |
| Discharge to community | 63.98% |
50.57%
13.4 pts better
|
Better than the National Rate · Eligible stays 445 · Observed rate 60.67% · Lower 95% interval 58.25% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 61.67% |
95.27%
33.6 pts worse
|
Numerator 140 · Denominator 227 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 227 |
| Discharge self-care score | 66.08% |
53.69%
12.4 pts better
|
Numerator 113 · Denominator 171 |
| Discharge mobility score | 43.27% |
50.94%
7.7 pts worse
|
Numerator 74 · Denominator 171 |
| Pressure ulcers or injuries, new or worsened | 1.76% |
2.29%
0.5 pts better
|
Numerator 4 · Denominator 227 · Adjusted rate 1.91% |
| Healthcare-associated infections requiring hospitalization | 5.18% |
7.12%
1.9 pts better
|
No Different than the National Rate · Eligible stays 267 · Observed rate 3.37% · Lower 95% interval 3.27% |
| Staff COVID-19 vaccination coverage | 6.63% |
8.2%
1.6 pts worse
|
Numerator 13 · Denominator 196 |
| Staff flu vaccination coverage | 31.68% |
42%
10.3 pts worse
|
Numerator 83 · Denominator 262 |
| Discharge function score | 55.56% |
56.45%
0.9 pts worse
|
Numerator 95 · Denominator 171 |
| Transfer of health information to provider | 90.91% |
95.95%
5 pts worse
|
Numerator 60 · Denominator 66 |
| Transfer of health information to patient | 92.09% |
96.28%
4.2 pts worse
|
Numerator 128 · Denominator 139 |
| Resident COVID-19 vaccinations up to date | 43.93% |
25.2%
18.7 pts better
|
Numerator 47 · Denominator 107 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
93.6%
5.7 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
95.4%
3.3 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.8%
0.3 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.5% · Q3 3.0% · Q4 5.8% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
24.6%
22.6 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 1.6% · Q4 4.5% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.6%
2.3 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 5.1% · Q3 7.4% · Q4 9.1% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.6% |
23.5%
8.1 pts worse
|
19.6%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.7% · Q2 28.8% · Q3 34.5% · Q4 26.3% · 4Q avg 31.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
14.8%
5.4 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 9.3% · Q3 7.5% · Q4 7.8% · 4Q avg 9.4% · 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 | 8.6% |
13.3%
4.7 pts better
|
16.3%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
11.7%
3.4 pts worse
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 10.0% · Q3 16.7% · Q4 20.4% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.4%
0.2 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.2%
0.7 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 4.5% · Q3 1.5% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.0% |
24.2%
1.2 pts better
|
19.8%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 30.8% · Q3 31.4% · Q4 15.4% · 4Q avg 23.0% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.1%
0.1 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 6.3% · Q3 2.3% · Q4 3.3% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
81.6%
11.1 pts better
|
81.7%
11 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.5% · Q2 91.6% · Q3 95.1% · Q4 94.0% · 4Q avg 92.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
10.5%
1.4 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.3% · Expected 10.1% · 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 0.9% · Q2 0.4% · Q3 0.4% · Q4 0.4% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.9% |
79.0%
10.9 pts better
|
79.7%
10.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
22.4%
2.4 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 21.5% · Expected 20.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-08 · Fire 2024-03-08
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-11-22 · Fire 2022-11-22
7 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
10 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
2025-05-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-04
F · Potential for more than minimal harm
2025-05-12
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-04
E · Potential for more than minimal harm
2024-03-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-30
E · Potential for more than minimal harm
2024-03-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-30
C · Minimal harm
2024-03-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-30
F · Potential for more than minimal harm
2022-11-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2022-12-28
F · Potential for more than minimal harm
2022-11-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-28
F · Potential for more than minimal harm
2022-11-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-28
F · Potential for more than minimal harm
2022-11-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-28
F · Potential for more than minimal harm
2022-11-22
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-11-22
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-11-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-11-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-11-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-28
E · Potential for more than minimal harm
2022-11-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-12-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-30
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 2026-02-20
F · Potential for more than minimal harm
2025-05-12
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 2025-06-06
E · Potential for more than minimal harm
2025-05-12
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 2025-06-06
E · Potential for more than minimal harm
2025-05-12
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-12
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-12
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 2025-06-06
D · Potential for more than minimal harm
2025-05-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-12
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-12
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 2025-06-06
D · Potential for more than minimal harm
2025-05-12
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 2025-06-06
D · Potential for more than minimal harm
2025-05-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-12
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
C · Minimal harm
2025-05-12
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-06-06
D · Potential for more than minimal harm
2024-03-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-08
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 2024-03-29
D · Potential for more than minimal harm
2024-03-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-29
D · Potential for more than minimal harm
2023-07-27
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 2023-08-19
E · Potential for more than minimal harm
2022-11-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-11-22
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 2023-01-06
D · Potential for more than minimal harm
2022-11-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-11-22
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 2023-01-06
D · Potential for more than minimal harm
2022-11-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-11-22
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 2023-01-06
Penalties and ownership
What sits behind the stars
Ownership
Hendricks County Hospital
5% Or Greater Direct Ownership Interest · Organization
Balla, Matthew
Operational/Managerial Control · Individual
Cardon And Associates Inc
Operational/Managerial Control · Organization
Cardon Management Company Ii LLC
Operational/Managerial Control · Organization
Cardon Management Company LLC
Operational/Managerial Control · Organization
Cattell, Zachary
Operational/Managerial Control · Individual
Craycraft, Allie
Operational/Managerial Control · Individual
Engels, Erin
Corporate Director · Individual
Fauth, Kendra
Operational/Managerial Control · Individual
Fenoughty, Deanna
Operational/Managerial Control · Individual
Fenoughty, Deanna
Corporate Officer · Individual
Gentry, Mark
Corporate Director · Individual
Gormal, Gregg
Operational/Managerial Control · Individual
Haug, Amy
Operational/Managerial Control · Individual
Hoyek, George
Operational/Managerial Control · Individual
Karner, Jim
Operational/Managerial Control · Individual
Lopossa, Lynn
Operational/Managerial Control · Individual
Lument Real Estate Capital LLC
5% Or Greater Security Interest · Organization
Mcclelland, Thomas
Operational/Managerial Control · Individual
Mcintosh, Eric
Operational/Managerial Control · Individual
Orix Real Estate Capital LLC
5% Or Greater Security Interest · Organization
Rodgers, Kent
Operational/Managerial Control · Individual
Starkey, Tyler
Corporate Director · Individual
Stewart, Robert
Operational/Managerial Control · Individual
Waite, John
Corporate Director · Individual
Whicker, Timothy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Prairie Lakes Health Campus
Noblesville, IN
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Allisonville Meadows
Fishers, IN
3-star overall rating with 2-star inspections with $11,190 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Castleton Health Care Center
Indianapolis, IN
1-star overall rating with 1-star inspections with 20 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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