Inspection Report
Plan of Correction
Deficiencies: 0
Jun 30, 2025
Visit Reason
Paper compliance review of the Annual Recertification and State Licensure survey and the Investigation of Complaint IN00444953 completed on May 12, 2025.
Findings
Hamilton Trace of Fishers was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the Recertification and State Licensure survey and the Investigation of Complaint IN00444953. The complaint was corrected.
Complaint Details
Complaint IN00444953 was investigated and found to be corrected.
Inspection Report
Life Safety
Census: 102
Capacity: 108
Deficiencies: 2
May 19, 2025
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements, specifically failing to ensure sprinkler system gauges were replaced or tested every 5 years and failing to conduct required maintenance and documentation for Patient Care Related Electrical Equipment (PCREE).
Severity Breakdown
SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure 14 of 16 sprinkler system gauges were replaced or tested every 5 years as required by NFPA 25. | SS=F |
| Failed to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE) as required by NFPA 99. | SS=F |
Report Facts
Certified beds: 108
Census: 102
Sprinkler system gauges: 16
Sprinkler system gauges not replaced/tested within 5 years: 14
Plan of Correction completion date: Jun 6, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allie Craycraft | Executive Director | Signed the report and plan of correction |
| Suzanne Williams | Director, Long-Term Care Division, Indiana State Department of Health | Referenced in the Plan of Correction letter |
Inspection Report
Recertification
Census: 70
Capacity: 166
Deficiencies: 15
May 12, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00444953.
Findings
The facility was found deficient in multiple areas including resident rights and dignity, privacy, medication administration, infection control, food safety and preparation, fall prevention, and care planning. Specific issues included failure to promote dignified environment, delayed call light responses, failure to maintain survey binder, privacy violations, improper medication storage, inadequate fall root cause analysis, and failure to serve diets as ordered.
Complaint Details
Complaint IN00444953 - Federal/State deficiencies related to the allegations are cited at F550, F583, and F661.
Severity Breakdown
SS=E: 3
SS=D: 7
SS=C: 1
SS=F: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to promote a dignified environment and timely care for residents, including call light response delays. | SS=E |
| Failed to have the most recent survey results available in the survey binder. | SS=C |
| Failed to ensure resident medical record privacy by giving wrong medical record at discharge. | SS=D |
| Failed to timely initiate and address a grievance regarding mattress comfort. | SS=D |
| Failed to ensure timely PASARR Level I and II screening for a resident. | SS=D |
| Failed to provide a discharge summary at time of discharge for a resident. | SS=D |
| Failed to trim nails and assist with transfers timely for residents. | SS=D |
| Failed to complete root cause analysis and implement fall interventions for residents with falls. | SS=D |
| Failed to ensure rationale for prophylactic antibiotic use and ongoing administration. | SS=D |
| Failed to serve food at palatable temperature for residents. | SS=E |
| Failed to serve diet as ordered by physician for a resident with dysphagia. | SS=D |
| Failed to ensure use of beard restraints by dietary staff, separate storage of personal lunch bag, coverage of frozen food and ready-to-eat dessert, and sanitary food distribution. | SS=F |
| Failed to ensure staff donned gown prior to administering medication via nasogastric tube and prior to urinary catheter and colostomy care for residents on enhanced barrier precautions. | SS=D |
| Failed to ensure residents had privacy regarding their personal belongings. | — |
| Failed to ensure a resident who was not safely able to self-administer medications did not have medications stored in their apartment. | — |
Report Facts
Survey dates: 6
Census: 166
Current census: 70
Residents affected: 14
Residents observed: 5
Audit frequency: 30
Audit frequency: 12
Audit frequency: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Observed administering medication via nasogastric tube without gown |
| CNA 7 | Certified Nurse Aide | Observed performing catheter and colostomy care without gown |
| DA 9 | Dietary Aide | Observed in kitchen without beard restraint |
| Housekeeper 30 | Alleged to have rummaged through residents' personal belongings | |
| LPN 31 | Licensed Practical Nurse | Interviewed about medication storage in Resident 48's apartment |
| Executive Director | Provided multiple policies and interviews | |
| Director of Nursing | Provided interviews and fall event reports | |
| Dietary Resource Manager | Interviewed about food temperature and safety |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 168
Deficiencies: 0
Oct 1, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00443949 and IN00437214.
Findings
No deficiencies related to the allegations in complaints IN00443949 and IN00437214 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00443949 and IN00437214 found no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 45
Census Bed Type - SNF: 56
Census Bed Type - Residential: 67
Total Capacity: 168
Census Payor Type - Medicare: 23
Census Payor Type - Medicaid: 46
Census Payor Type - Other: 32
Total Census: 101
Inspection Report
Re-Inspection
Census: 103
Capacity: 108
Deficiencies: 0
May 30, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/05/24 was performed to verify compliance with life safety and licensure requirements.
Findings
At this PSR survey, Hamilton Trace of Fishers was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinkled except for one detached storage building.
Report Facts
Facility capacity: 108
Census: 103
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
Apr 17, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00431289.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00431289 - No deficiencies related to the allegations are cited.
Report Facts
Census: 106
Census Bed Type Total: 106
Census Payor Type Total: 106
Inspection Report
Life Safety
Census: 103
Capacity: 108
Deficiencies: 3
Apr 5, 2024
Visit Reason
The inspection was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with Life Safety Code requirements due to deficiencies including an incorrect year displayed on the fire alarm control panel, four sprinkler heads at the main entrance overhang being dirty and corroded, and two electrical panels in the Companion Hall corridor unsecured from unauthorized personnel.
Severity Breakdown
SS=C: 1
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Fire alarm control panel displayed incorrect year (2004 instead of 2024). | SS=C |
| Four of ten sprinkler heads at the main entrance overhang were dirty, corroded, and covered with foreign material. | SS=E |
| Two electrical panels in the Companion Hall corridor were unsecured and accessible to non-authorized personnel. | SS=E |
Report Facts
Certified beds: 108
Census: 103
Sprinkler heads affected: 4
Electrical panels unsecured: 2
Sprinkler heads inspected: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allie Craycraft | Executive Director | Participated in exit conference and signed plan of correction |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of plan of correction letter |
| Maintenance Director | Interviewed regarding fire alarm panel, sprinkler heads, and electrical panel deficiencies |
Inspection Report
Recertification
Census: 67
Capacity: 170
Deficiencies: 4
Mar 8, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00424343. The visit included a State Residential Licensure Survey.
Findings
The facility was found to have deficiencies related to accuracy of assessments, failure to use gait belts during resident transfers, untimely administration of medications, and failure to maintain infection prevention and control practices. The facility was also found to be in compliance with State Residential Licensure Survey requirements.
Complaint Details
Complaint IN00424343 was investigated and Federal/State deficiencies related to the allegations were cited at F0755, F0684, and F0880.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure accuracy of Minimum Data Set (MDS) assessments regarding restraint use and discharge location for 1 of 1 residents reviewed. | SS=D |
| Failed to ensure a gait belt was utilized during resident transfers and fall prevention measures were implemented for 1 of 6 residents reviewed. | SS=D |
| Failed to timely administer an antibiotic as ordered and allowed duplicate antidepressant therapy for 2 of 6 residents reviewed for unnecessary medications. | SS=D |
| Failed to maintain an infection prevention and control program by not ensuring a urinary catheter's tubing was off the floor for 1 of 2 residents reviewed. | SS=D |
Report Facts
Survey dates: March 5, 6, 7, and 8, 2024
Census Bed Type - SNF/NF: 54
Census Bed Type - SNF: 49
Census Bed Type - Residential: 67
Total Capacity: 170
Census Payor Type - Medicare: 39
Census Payor Type - Medicaid: 41
Census Payor Type - Other: 23
Total Census: 103
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 8, 2024
Visit Reason
Paper compliance review for the Recertification, State Licensure, Residential and Investigation of Complaint.
Findings
Hamilton Trace of Fishers was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for Recertification, State Licensure, Residential and Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 177
Deficiencies: 0
Aug 31, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414527, IN00415121, and IN00415549.
Findings
No deficiencies related to the allegations in complaints IN00414527, IN00415121, and IN00415549 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00414527, IN00415121, and IN00415549 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 177
Census Payor Type Total: 108
SNF/NF Beds: 56
SNF Beds: 52
Residential Beds: 69
Medicare Residents: 14
Medicaid Residents: 39
Other Payor Residents: 55
Inspection Report
Complaint Investigation
Census: 106
Capacity: 171
Deficiencies: 1
Jul 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413414 regarding federal and state deficiencies related to allegations of resident care.
Findings
The facility failed to ensure a dependent resident (Resident C) did not fall out of bed during personal care and that nursing staff followed the resident's plan of care for accident prevention. The investigation revealed that one CNA was providing care alone despite the care plan requiring two staff for assistance, resulting in the resident falling and sustaining injury.
Complaint Details
Complaint IN00413414 was substantiated with federal/state deficiencies cited at F689 related to the fall incident involving Resident C.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure resident environment remained free of accident hazards and adequate supervision to prevent falls for Resident C. | SS=D |
Report Facts
Census: 106
Total Capacity: 171
Deficiency cited: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allie Craycraft | Executive Director | Signed the report |
| CNA 2 | Certified Nursing Assistant | Named in the fall incident involving Resident C |
| CNA 4 | Certified Nursing Assistant | Interviewed regarding care of Resident C |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing and incident |
| Therapy Director | Therapy Director | Interviewed regarding Resident C's therapy and assistance needs |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 27, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Investigation of Complaint IN00413414 completed on July 27, 2023.
Findings
Hamilton Trace of Fishers was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00413414 completed on July 27, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 94
Capacity: 160
Deficiencies: 0
Jun 26, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411190.
Findings
No deficiencies related to the allegations in Complaint IN00411190 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00411190 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 52
Census Bed Type - SNF: 42
Census Bed Type - Residential: 66
Census Bed Type - Total: 160
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 32
Census Payor Type - Other: 51
Census Payor Type - Total: 94
Inspection Report
Complaint Investigation
Census: 104
Capacity: 170
Deficiencies: 0
Apr 27, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00406850 and IN00406987.
Findings
No deficiencies related to the allegations in complaints IN00406850 and IN00406987 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00406850 and IN00406987 found no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 54
Census Bed Type - SNF: 50
Census Bed Type - Residential: 66
Total Capacity: 170
Census Payor Type - Medicare: 16
Census Payor Type - Medicaid: 35
Census Payor Type - Other: 53
Total Census: 104
Inspection Report
Complaint Investigation
Census: 100
Capacity: 168
Deficiencies: 0
Apr 13, 2023
Visit Reason
This visit was conducted as an investigation of Complaint IN00398494.
Findings
No deficiencies related to the allegations in Complaint IN00398494 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00398494 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 55
Census Bed Type - SNF: 45
Census Bed Type - Residential: 68
Census Bed Type - Total Capacity: 168
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 36
Census Payor Type - Other: 50
Census Payor Type - Total Census: 100
Inspection Report
Deficiencies: 0
Jan 26, 2023
Visit Reason
The inspection was a paper compliance review related to the Recertification, State Licensure, Investigation of Complaint IN00391026 Survey, including a Residential Survey completed on November 22, 2022.
Findings
Hamilton Trace of Fishers was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for Recertification, State Licensure, Complaint Investigation, and Residential Licensure Survey.
Inspection Report
Re-Inspection
Census: 103
Capacity: 108
Deficiencies: 0
Jan 12, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey following the initial surveys conducted on 12/12/22.
Findings
At the PSR Emergency Preparedness survey, the facility was found in compliance with Emergency Preparedness Requirements. At the PSR Life Safety Code survey, the facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinkled except for one detached storage building.
Report Facts
Certified beds: 108
Census: 103
Inspection Report
Life Safety
Census: 102
Capacity: 108
Deficiencies: 12
Dec 12, 2022
Visit Reason
An Emergency Preparedness and Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements including deficiencies in emergency power system testing, fire door latching, hazardous area door self-closing devices, sprinkler system maintenance, corridor door latching, electrical outlet protection, fire drills, generator testing, power strip usage, and oxygen transfilling signage.
Severity Breakdown
SS=E: 7
SS=F: 5
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility generator lacked documented 3-year 4-hour load bank test and annual diesel fuel quality test. | — |
| Double fire doors in AL Dining area did not close and latch, failing to limit smoke spread. | SS=E |
| Staff Development Office door lacked self-closing device and was declared a hazardous area due to excess combustible boxes. | SS=E |
| Sprinkler system lacked documentation of internal pipe inspection and monthly inspection of dry pipe sprinkler gauges and valves was incomplete. | SS=F |
| Sprinkler heads in laundry area were covered with dust and lint, showing signs of loading. | SS=F |
| Corridor door to 400 Hall Soiled Utility area did not close and latch positively, failing to resist smoke passage. | SS=E |
| Electrical outlet in mechanical room near resident room #807 was not enclosed and had exposed terminals. | SS=E |
| Resident room 604 used multi-plug adaptor for medical equipment, lamp, and electronics, violating fixed wiring requirements. | SS=E |
| Power strip in Delaware Activity Room was not secured and was dangling from the wall. | SS=E |
| Oxygen storage/transfer rooms lacked posted signs indicating when transfilling is occurring and smoking prohibition. | SS=F |
| Facility failed to conduct or document fire drills or orientation training on each shift for 2 of 4 quarters. | SS=F |
| Emergency power system generator lacked documented 3-year 4-hour load bank test and annual fuel quality test. | SS=F |
Report Facts
Certified beds: 108
Census: 102
Deficiencies cited: 12
Fire drill quarters missing: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Allie Craycraft | Executive Director | Named in relation to plan of correction and exit conference |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 172
Deficiencies: 12
Nov 22, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00391026, including a State Residential Licensure Survey.
Findings
The facility was found deficient in multiple areas including grievance policy implementation, background checks for new hires, accuracy of assessments, ADL care, activity programming, medication administration, fall interventions, transfer-discharge documentation, policy availability, and infection control related to TB testing.
Complaint Details
Complaint IN00391026 was substantiated with Federal/State deficiencies cited at F677 and F684.
Severity Breakdown
SS=D: 5
SS=A: 1
SS=E: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure prompt attention to resident grievances and to develop a grievance policy. | SS=D |
| Failed to ensure a criminal background check was obtained for a new hire per facility policy. | SS=D |
| Failed to ensure accuracy of a Minimum Data Set (MDS) assessment for Preadmission Screening and Resident Review (PASRR). | SS=A |
| Failed to provide necessary services for grooming and personal hygiene including twice weekly showers and timely incontinent care. | SS=D |
| Failed to provide an ongoing activity program on the memory care unit and timely assistance to activities. | SS=E |
| Failed to ensure transportation to wound care specialist appointment, administration of eye drops as ordered, and timely physician notification of significant weight gain. | SS=D |
| Failed to implement fall interventions as care planned for residents reviewed for accidents. | SS=D |
| Failed to ensure appropriate state-mandated transfer-discharge documents were completed and placed in resident's clinical record. | — |
| Failed to develop and implement written policies for the Residential portion of the facility. | — |
| Failed to identify and document the services to be provided by the facility (service plan) for a resident. | — |
| Failed to ensure PRN medications administered by a qualified medication aide were authorized by a licensed nurse or physician prior to administration. | — |
| Failed to ensure tuberculin skin tests were completed within 90 days of admission and read within 48 to 72 hours for new admissions. | — |
Report Facts
Survey dates: 6
Census Bed Type: 172
Census Payor Type: 102
Deficiencies cited: 12
Weight gain: 14
Fall mattress intervention start date: Jan 27, 2022
Fall dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 7 | Licensed Practical Nurse | Described Resident 73 and provided information about transfer documentation |
| LPN 32 | Licensed Practical Nurse | Reviewed personnel file and bed mattress for Resident 28 |
| CNA 33 | Certified Nursing Assistant | Assisted Resident 68 with non-skid socks and described resident care |
| NC | Nurse Consultant | Reviewed personnel files and PRN medication authorization |
| Executive Director | Provided information about policies and grievance procedures | |
| AD | Activity Director | Described activity programming and staffing |
| CN | Corporate Nurse | Provided grievance policy information |
| HRD | Human Resource Director | Discussed background check policy and new hire procedures |
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