01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-12 | 15 | 2025-05-12 | 2 |
| Cycle 2 | 2024-03-08 | 4 | 2024-03-08 | 3 |
| Cycle 3 | 2022-11-22 | 6 | 2022-11-22 | 10 |
CMS CCN 1557932026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Hamilton Trace Of Fishers
11851 Cumberland Rd · Fishers, IN 46037 · Hamilton County
Certified beds108CMS provider file
Recent citation rows40current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
40 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-02-10 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-02-27 · complaint2026-01-30 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2026-02-20 · complaint2025-05-12 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-12 · HEALTHF0577Severity C · widespread; potential for minimal harm
Resident Rights Deficiencies
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-12 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2025-06-06 · complaint2025-05-12 · HEALTHF0585Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-12 · HEALTHF0645Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-12 · HEALTHF0661Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Correction field: Deficient, Provider has date of correction · 2025-06-06 · complaint2025-05-12 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-06-06 · complaint2025-05-12 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-12 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-12 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-12 · HEALTHF0805Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-12 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-12 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-05-12 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-09-042025-05-12 · FIREK0921Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Correction field: Deficient, Provider has date of correction · 2025-09-042024-03-08 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2024-03-292024-03-08 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-03-292024-03-08 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-03-29 · complaint2024-03-08 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-03-292024-03-08 · FIREK0345Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2024-05-302024-03-08 · FIREK0353Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-05-302024-03-08 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2024-05-3003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LUMENT REAL ESTATE CAPITAL LLCOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 04/22/2015
- ORIX REAL ESTATE CAPITAL LLCOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 04/22/2015
- ENGELS, ERINIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 10/12/2012
- FENOUGHTY, DEANNAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 07/10/2023
- GENTRY, MARKIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/12/2022
- STARKEY, TYLERIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/01/2020
- WAITE, JOHNIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 08/01/2020
- WHICKER, TIMOTHYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/12/2022
- ENGELS, ERINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/01/2014
- GENTRY, MARKIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/12/2022
- STARKEY, TYLERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/01/2020
- WAITE, JOHNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/01/2020
- WHICKER, TIMOTHYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/12/2022
- FENOUGHTY, DEANNAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/10/2023
- CARDON AND ASSOCIATES INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/23/2013
- CARDON MANAGEMENT COMPANY II LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/17/2013
- CARDON MANAGEMENT COMPANY LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/17/2013
- BALLA, MATTHEWIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/23/2022
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.74per resident day
RN hours0.73per resident day
Weekend nurse hours3.20per resident day
Staff turnover36.2%CMS reported field
06 / LOCAL RECORDS
Open the Fishers ledger →