Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Hamilton Trace Of Fishers during CMS and state inspections, most recent first.
A resident receiving wound care to a right lower extremity and sacral wound under Enhanced Barrier Precautions was treated by an RN and a Wound Care Nurse who repeatedly changed gloves without performing required hand hygiene. During the procedure, including after removal of soiled dressings and after cleaning an incontinent bowel movement, both nurses discarded gloves and donned new ones without handwashing or hand sanitizer use, contrary to the facility’s written wound care and infection control procedures that require hand hygiene before and after glove use and between wound care steps.
A resident with central cord syndrome and neuromuscular bladder dysfunction had significant urinary retention and an indwelling catheter was anchored per an on-call provider’s direction, with instructions in a physician note to monitor urine output and clamp the catheter above a specified volume. However, the clinical record lacked a formal physician order for the indwelling catheter, catheter care, or urine output monitoring, and catheter care every shift was not documented. The DON reported being unable to locate the catheter order, was unaware of the physician’s documented instructions to monitor urine output, and stated staff did not record urine output without a specific order.
Surveyors found that dietary staff failed to use proper beard restraints, stored a personal lunch bag with facility food, left frozen and ready-to-eat desserts uncovered, and distributed food under unsanitary conditions. These actions were not in accordance with facility policies and had the potential to affect all residents.
Multiple residents experienced significant delays in staff response to call lights, with some waiting up to an hour for assistance, and one resident was observed undressed in a public area despite having clothing available and expressing a desire to be dressed. Resident council meetings repeatedly documented concerns about slow response times, and observations confirmed that staff did not consistently meet the facility's own standards for timely care and resident dignity.
Multiple residents reported receiving cold food, and resident council minutes documented ongoing concerns about food temperature. Test trays showed food items were served below the required 135°F holding temperature, and staff confirmed this standard was not met, despite facility policy requiring prompt delivery to maintain food quality.
A resident was discharged and mistakenly given another resident's medical record due to an error at the nurse's station, where both records were placed together. The mistake was discovered a day later when the resident presented the incorrect chart at the hospital, leading to a breach of privacy and confidentiality.
A resident with cellulitis and a right heel wound repeatedly reported that her mattress caused significant back pain and requested a different mattress or a recliner, but her complaints were not formally documented or addressed in a timely manner. Staff, including CNAs and a nurse, were informed of her discomfort, but the DON was unaware of the issue, and grievance forms were not completed as required by facility policy.
A resident with dementia, bipolar disorder, and depression was admitted without a timely PASRR Level I and Level II screening. Facility records showed several incomplete or expired attempts before the screening was finally completed and referred, and staff interviews revealed uncertainty about PASRR requirements and a lack of policy.
Two residents did not receive timely assistance with ADLs: one resident's nails remained untrimmed despite repeated requests and observations, and another resident with paraplegia experienced significant delays in being transferred back to bed, resulting in discomfort. Staff confirmed that care delays occurred during busy periods, and documentation did not reflect that required care was provided.
Three residents experienced multiple falls due to the facility's failure to conduct thorough root cause analyses and to implement or document individualized fall prevention interventions as care planned. For example, a resident with dementia had repeated unwitnessed falls with only superficial analysis by the IDT, another with Parkinson's disease was not consistently offered or documented as using hip protectors, and a third resident did not receive bed bolsters as planned, with conflicting accounts about refusal and lack of documentation.
Three residents with histories of urinary tract infections received ongoing prophylactic antibiotics without documented rationale for continued use. In one case, a resident was given two antibiotics simultaneously without justification, while in others, there was no evidence of ongoing evaluation or provider discussion regarding the necessity of the prophylactic regimen. Facility staff indicated that decisions were left to provider judgment, and antibiotic stewardship practices were not consistently applied.
A resident with dysphagia, who was ordered a mechanically altered diet with ground meat, was initially served a meal that did not meet dietary requirements, including a tossed salad with unshredded lettuce. The Director of Dining Services confirmed this was not compliant with the facility's diet guidelines.
Staff did not consistently don gowns as required by enhanced barrier precautions (EBP) when providing high-contact care to two residents, including medication administration via nasogastric tube and catheter/colostomy care. Although gloves were used, gowns were omitted despite facility policy and physician orders mandating both gown and glove use for residents on EBP.
The facility did not have the most recent survey results available in the survey binder accessible to residents and families, as only outdated information from 2022 was present despite a more recent survey having been conducted. This was confirmed during a resident council meeting and through observation with the Executive Director, who was unsure why the latest survey was not included.
Failure to Perform Required Hand Hygiene During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection control policies and procedures for hand hygiene during wound care for one resident under Enhanced Barrier Precautions. During an observed wound care session for a resident with a right lower extremity (RLE) wound and a sacral wound, an RN and the Wound Care Nurse repeatedly removed and changed gloves without performing hand hygiene or handwashing as required by facility policy. After removing the dressing from the RLE wound, both nurses discarded their gloves and donned new ones without any observed hand hygiene. Following completion of treatment to the RLE wound, they again removed and discarded gloves, then applied new gloves without hand hygiene before repositioning the resident for care of the sacral wound. When the resident was repositioned, he was found to have an incontinent bowel movement, and both nurses removed and discarded their gloves, then donned new gloves to clean the resident and continue wound care, again without any observed hand hygiene or handwashing. The RN then provided sacral wound care, removed and discarded gloves, and applied new gloves without hand hygiene, and both nurses assisted the resident into a position of comfort and cleaned the area, removing and discarding gloves at the end without performing hand hygiene. In subsequent interviews, both the RN and the Wound Care Nurse acknowledged that hand hygiene or handwashing should have occurred between wounds and after cleaning the bowel movement. Review of the facility’s wound care procedure showed multiple explicit requirements to wash hands or perform hand hygiene before and after glove use and between steps of the wound care process, which were not followed during this observed care.
Failure to Obtain and Implement Orders for Indwelling Catheter Care and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide and document appropriate catheter care, monitoring, and urine output documentation for a resident with an indwelling urinary catheter. The resident had diagnoses including central cord syndrome and neuromuscular dysfunction of the bladder, with a physician’s order for bladder scans every shift and provider notification if residual urine exceeded 200 milliliters. On one evening, the resident’s bladder scan showed 855 milliliters of urine with abdominal firmness, and the physician documented a plan to anchor an indwelling catheter, monitor urine output, clamp the catheter if output exceeded 600 milliliters, and not remove the catheter until the resident was seen by the physician. A subsequent nursing note indicated an on-call provider ordered the catheter to be anchored, with staff to monitor urine output and clamp the catheter if output was greater than 600 milliliters, and confirmed the catheter had been anchored. Despite these clinical notes, the resident’s record did not contain a corresponding physician’s order for the indwelling catheter, catheter care treatment orders, or orders for monitoring urine output as described in the physician’s note. The January MAR/TAR reflected the high residual urine amount but did not include the detailed catheter-related orders. During interview, the DON stated he could not locate a physician’s order for the indwelling catheter, acknowledged the on-call physician had given the order by phone to anchor the catheter, and indicated staff did not record urine output unless there was a specific physician order. The DON was unaware of the physician’s note directing staff to monitor urine output, and catheter care every shift for residents with indwelling catheters was not documented for this resident.
Deficient Food Handling and Sanitation Practices Observed
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations. During a kitchen tour, a dietary aide was seen working without a beard restraint, instead wearing a surgical mask below his chin, which did not comply with the facility's policy requiring effective coverage of facial hair. In the walk-in freezer, four bowls of uncovered chocolate ice cream were found on a tray, and a personal lunch bag containing vendor ice cream samples was stored on a rack alongside facility food items. Additionally, in the main dining room, plates of dessert cakes were left uncovered and partially stacked on a cart. Interviews with the kitchen supervisor confirmed that the dietary aide was incorrectly told a surgical mask could substitute for a beard restraint and acknowledged that the uncovered ice cream should have been discarded earlier. Facility policies provided by the Director of Dining Services specified that all dietary staff must wear appropriate hair restraints and that all opened foods must be covered to protect from contamination. These lapses in food storage, preparation, and distribution practices had the potential to affect all residents in the facility.
Failure to Ensure Timely Care and Resident Dignity
Penalty
Summary
The facility failed to promote a dignified environment and provide timely care and services to residents, as evidenced by multiple instances of delayed response to call lights and failure to ensure residents were appropriately dressed. Several residents, both cognitively intact and impaired, reported or were observed experiencing significant delays in staff response after activating their call lights, with some waiting up to an hour or more for assistance. In one case, a resident was observed with her call light on for approximately 20 minutes, sitting on the edge of her bed with her underwear pulled down, while staff walked past without responding. Other residents reported similar delays, particularly during high care activity times or meal service, with one resident being told she would have to wait until meal service was completed before receiving pain medication. Resident council meeting minutes from several months documented ongoing concerns from residents about slow call light response times. Despite staff education and in-service training on the importance of timely call light response, residents continued to voice dissatisfaction with the timeliness of care. The facility's own policy set a goal of answering call lights within 10 minutes, but this standard was not consistently met, as confirmed by both resident interviews and direct observation by surveyors. Additionally, the facility failed to ensure that residents were dressed in street clothes while dining in the facility dining room. One resident was observed sitting in a wheelchair in the dining room and later in her room, dressed only in a hospital gown with part of her back exposed, despite having clothing available and expressing a desire to be dressed. This lack of attention to residents' dignity and personal preferences further contributed to the deficiency, as it did not align with the facility's policy to promote a dignified existence and respect for residents' individuality.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and safe temperature for all 14 residents reviewed. Multiple residents reported that their food was delivered cold, including one resident with cellulitis and another with hypertension. Resident council meeting minutes from three consecutive months documented repeated concerns from several residents about food being served cold. A test tray delivered after all residents on one hall received their meals showed food temperatures below the required holding temperature of 135 degrees Fahrenheit, with pizza ranging from 110 to 134.9 degrees Fahrenheit and cobbler from 99.4 to 110 degrees Fahrenheit. The Dietary Resource Manager confirmed that holding temperatures should be at least 135 degrees. Facility policy stated that trays should be delivered promptly to ensure food is served at a preferable temperature and to preserve quality, but this was not followed.
Failure to Maintain Privacy and Confidentiality of Medical Records at Discharge
Penalty
Summary
A resident was discharged from the facility and was mistakenly given another resident's medical record at the time of discharge. Both residents involved had been discharged on the same day, and their medical records were placed in folders on top of the nurse's station. A nurse inadvertently provided the wrong medical chart to the departing resident. The error was not identified until 24 hours later, when the resident presented the incorrect medical chart at the emergency room, and hospital staff recognized the mistake and notified the facility. The residents involved had diagnoses including stroke and pain, respectively. The facility's policy, as provided by the Executive Director, states a commitment to protecting residents' rights, including access to their own personal and medical records and ensuring privacy and confidentiality. The incident resulted in a failure to maintain the privacy and confidentiality of a resident's medical record.
Failure to Timely Address Resident Grievance Regarding Mattress and Pain
Penalty
Summary
The facility failed to timely initiate and address a grievance for a resident who had ongoing complaints about discomfort caused by her mattress and back pain. The resident, who had a diagnosis of cellulitis in the right lower limb and a wound to the right heel, repeatedly informed staff that her mattress was uncomfortable and exacerbated her back pain. She reported her concerns to multiple staff members, including certified nurse aides and a nurse, and requested a different mattress and a recliner, which she had used at home. Despite these repeated complaints, no grievance was formally documented, and her requests were not addressed in a timely manner. The resident spent extended periods in her wheelchair due to the discomfort and was told on several occasions that a recliner could be provided, but this was not followed through until later. Interviews with facility staff revealed that the Director of Nursing was not aware of the resident's complaints or requests, and the staff assigned to check on the resident daily did not document or escalate the grievance. Additionally, registered nurses on the unit indicated that grievance forms were not readily available, and their process for handling concerns was to notify the relevant department or unit manager rather than completing a formal grievance form. The facility's policies required that grievances be documented immediately and investigated, but this process was not followed for the resident's ongoing complaints.
Failure to Complete Timely PASRR Screening
Penalty
Summary
A deficiency occurred when the facility failed to ensure a timely Level I and Level II PASRR screening was obtained for a resident with diagnoses including dementia, bipolar disorder, and depression. The resident was admitted without evidence of a completed PASRR Level I screen, and the facility's records showed multiple attempts to start the screening, which were either withdrawn or expired before completion. The Level I screen was eventually completed and referred for Level II screening, but this was not done in a timely manner. Interviews with the Social Services Director revealed uncertainty about the PASRR process and timing, and the DON confirmed the absence of a PASRR policy. Documentation indicated that the resident had diagnoses that could impact adjustment, but the required screenings were not completed as required upon admission.
Failure to Provide Timely ADL Assistance and Nail Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents. One resident, with a history of cellulitis and depression, reported that her fingernails were long and needed trimming. Observations confirmed that her nails extended well past her fingertips and had worn green polish. Despite receiving a bed bath, documentation did not indicate that nail care was provided or refused, and the resident continued to report untrimmed nails over several days. Staff interviews confirmed that nail trimming should occur on shower days and as needed, but this was not documented or completed for the resident. Another resident, diagnosed with paraplegia and a history of repeated falls, required staff assistance for transfers. The resident was observed waiting for an extended period with her call light on, expressing discomfort and pain from wounds on her backside while waiting to be transferred back to bed. She indicated that staff told her she would have to wait until after lunch for assistance. Staff interviews and observations confirmed that care delays occurred during high care times, such as mealtimes, resulting in the resident having to wait for necessary assistance with transfers.
Failure to Analyze and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to conduct thorough root cause analyses of falls and did not consistently implement or document fall prevention interventions as care planned for three residents. For one resident with Alzheimer's disease and severe cognitive impairment, multiple falls occurred, some unwitnessed, with the clinical record lacking detailed interdisciplinary team (IDT) notes for certain incidents. The IDT's root cause analyses were limited to describing the circumstances in which the resident was found, without deeper investigation into underlying causes. Interventions such as offering naps and assessing footwear were noted, but the documentation did not reflect a comprehensive analysis using the facility's own '5 Whys' policy, as required. Another resident with Parkinson's disease, a history of repeated falls, and orthostatic hypotension experienced several unwitnessed falls resulting in injuries. The care plan included the use of hip protectors, but there was no evidence in the electronic health record that staff consistently offered or documented the resident's use or refusal of the hip protectors. Interviews revealed that the resident had not worn the hip protectors and staff were unsure of their location or whether they had been offered, indicating a lack of follow-through on the care plan interventions and documentation requirements. A third resident, dependent on staff for transfers and with a history of stroke and unsteadiness, was care planned to have bed bolsters added for fall prevention after an unwitnessed fall. Observations on multiple occasions showed that bed bolsters were not present on the resident's bed, and there was conflicting information regarding whether the resident had refused them. The care plan was updated to indicate refusal, but there was no supporting documentation in the electronic health record, and the resident's representative reported that staff had not returned to install the bolsters after an initial attempt. These findings demonstrate failures in both implementing and documenting individualized fall prevention interventions as required by facility policy.
Lack of Rationale and Ongoing Evaluation for Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary drugs, specifically regarding the ongoing use of prophylactic antibiotics for the prevention of urinary tract infections (UTIs) in three residents. For one resident with chronic kidney disease and a history of UTIs, a prophylactic antibiotic (Macrobid) was ordered and administered daily without documented rationale for its continued use. When this resident developed UTI symptoms and was prescribed an additional antibiotic (Bactrim), both antibiotics were administered simultaneously, yet there was no documentation justifying the ongoing use of the prophylactic antibiotic during this period. Another resident with Alzheimer's disease and a history of UTIs had been receiving daily Macrobid since hospital discharge for UTI symptoms, with no documentation in the electronic health record regarding the rationale for the continued prophylactic antibiotic use. The Infection Preventionist (IP) confirmed that tracking of prophylactic antibiotics was only done for the first month and that there had been no discussion with the medical provider about the ongoing need for the antibiotic in this case. A third resident with benign prostatic hyperplasia and a history of UTIs had been on prophylactic Macrobid since admission, with no end date or documented rationale for continuation. The IP and DON both indicated that decisions regarding prophylactic antibiotics were left to the provider's judgment, and there was no ongoing tracking or documentation of indications, side effects, or rationale for continued use. Facility policy referenced antibiotic stewardship, but in practice, there was no evidence of ongoing evaluation or provider feedback regarding these residents' antibiotic regimens.
Failure to Provide Diet Consistent with Physician Order for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of dysphagia, who had a physician's order for a mechanically altered diet with ground meat, was initially served a meal that did not comply with the prescribed diet. The resident was observed receiving a plate containing a sandwich, tossed salad, and root vegetables, which was then removed and replaced with a plate containing ground meat, root vegetables, and tossed salad. The meal ticket indicated the resident required a mechanical soft with ground meat diet. The Director of Dining Services confirmed that the tossed salad should not have been served because the lettuce was not shredded, which was inconsistent with the facility's Mechanical or Dental Soft Diet guidelines that prohibit raw vegetables except for shredded lettuce.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
Staff failed to follow enhanced barrier precautions (EBP) protocols for two residents requiring additional infection control measures. For one resident with dysphagia and a pressure ulcer, an LPN administered medication via a nasogastric tube after performing hand hygiene and donning gloves, but did not wear a gown as required by EBP. The LPN later stated uncertainty about the need for a gown during this procedure. For another resident with diverticulosis, neuromuscular bladder dysfunction, a urinary tract infection, an indwelling urinary catheter, and an ostomy, staff did not don a gown during catheter and colostomy care, despite the resident being on EBP per physician order and care plan. Observations and interviews confirmed that gloves were used, but gowns were not, during high-contact care activities. Facility policy required both gown and glove use for such activities under EBP, but this was not consistently followed by staff.
Failure to Provide Most Recent Survey Results in Public Binder
Penalty
Summary
The facility failed to make the most recent survey results available in the survey binder, which had the potential to affect all 97 residents currently residing in the facility. During a resident council meeting, a family member reported being unable to view the most recent survey results in the binder located by the front entrance, as it only contained information from 2022. Upon observation with the Executive Director, it was confirmed that the most recent survey present was from December 2022, despite an annual recertification survey having been conducted in March 2024. The Executive Director acknowledged that the latest survey should have been included in the binder but was unsure why it was missing.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 971 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fishers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie Lakes Health Campus | 2.7 mi | ★★★★★ | 3 | 0 |
| Allisonville Meadows | 3.5 mi | ★★★★★ | 25 | 0 |
| Castleton Health Care Center | 3.9 mi | ★★★★★ | 36 | 0 |
| Waters Of Castleton Skilled Nursing Facility, The | 4.1 mi | ★★★★★ | 24 | 0 |
| Clearvista Lake Health Campus | 4.1 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hamilton Trace Of Fishers.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.