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
Staffing
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing
LPN hours / resident day
1.19
Licensed practical nurse staffing
Aide hours / resident day
1.70
Nurse aide staffing
Weekend hours
3.20
Weekend nurse staffing
RN turnover
13%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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