Hamilton Trace of Fishers

In the surveyor’s words

From the most serious findings on record at Hamilton Trace of Fishers, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 12, 2025

  Based on observation, interview, and record review, the facility failed to ensure the use of beard restraints by dietary staff, separate storage of a personal lunch bag, ensure coverage of stored frozen food and ready-to-eat dessert, and distribution of food under sanitary conditions. This had the potential to affect 96 of 96 residents in the facility. Findings include: A kitchen tour was conducted, on 5/5/25 at 9:30 a.m., with the [NAME] Supervisor (CS). Dietary Aide (DA) 9 was observed in the kitchen without the use of a beard restraint to cover his facial hair and instead was wearing a surgical mask below his chin. An observation of the walk-in freezer was made during the tour. Four bowls of uncovered chocolate ice cream were observed on a tray. […]

• No harm, potential for more than minimal, widespreadF729Nov 22, 2022

  Based on interview and record review, the facility failed to ensure/follow up that a nurse aide had an active CNA (Certified Nursing Assistant) certification timely. This had the potential to effect 102 of 102 residents who reside on the certified section of the facility and 70 of 70 residents who reside on the Assisted Living section of the facility. Findings include: An interview with ED (Executive Director) conducted on [DATE] at 10:30 a.m. indicated, the facility has an Assisted Living (AL) attached to the building as well as the Skilled Nursing and staff work between the two sections of the facility, but some primarily work on the Assisted Living. […]

• No harm, potential for more than minimal, patternF550May 12, 2025

  Based on interview and record review, the facility failed to promote a dignified environment with not providing care and services timely and ensure a resident was dressed in street clothes while dining in the facility dining room for 14 of 18 residents reviewed for resident council, 3 of 7 residents reviewed for Activities of Daily Living, 1 of 4 residents reviewed for staffing and 2 of 2 residents randomly observed. (Resident D, Resident E, Resident F, Resident G, Resident H, Resident J, Resident K, Resident L, Resident M, Resident N, Resident O, Resident P, Resident Q, Resident R, Resident S, Resident T, Resident X, Resident V, Resident W, Resident Z, Resident DD, Resident EE and Resident C) Findings include: 1. The clinical record for Resident V was reviewed on 5/12/25 at 11:12 a.m. […]

• No harm, potential for more than minimal, patternF804May 12, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was served at a palatable temperature for 14 of 14 residents reviewed for food. (Residents D, F, G, H, J, N, O, Q, R, T, X, 84, Z, and DD) Findings include: 1. The clinical record for Resident DD was reviewed on 5/6/25 at 11:00 a.m. The diagnoses included, but were not limited to, cellulitis. During an interview with Resident DD on 5/6/25 at 11:03 a.m., she indicated the food was delivered cold. 2. The clinical record for Resident 84 was reviewed on 5/5/25 at 11:15 a.m. The diagnoses included, but were not limited to, hypertension. An interview was conducted with Resident 84 on 5/5/25 at 11:37 a.m. She indicated the food was often served cold. 51750 3. […]

• No harm, potential for more than minimal, patternF684Mar 8, 2024

  3. The clinical record for Resident D was reviewed on 3/8/24 at 3:10 p.m. Resident D's diagnoses included, but not limited to, fracture of lower end of right femur, major depressive disorder, and lymphadema. A Brief Interview for Mental Status (BIMS) assessment conducted on 3/7/24 indicated, Resident D was cognitively intact. An observation and interview with Resident D conducted on 3/6/24 at 10:09 a.m. indicated, Resident D was lying in bed with the right leg immobilizer on her leg. When asked about having her heels floated while in bed, she indicated, no one had educated her on why she should have her heels floated while in bed nor did she know how to float her heels. She further indicated, it was difficult for her to turn herself independently while in bed. […]