A-
86/100RETREAT AT THE STRATFORD, THE Inspection Report, Violations & Safety Grade (CARMEL, Indiana)
2460 GLEBE ST, CARMEL, Indiana 46032
Phone: 3177339560
CMS Overall:4/5
Overview & Bed Count
Certified Beds
18
Avg Residents/Day
11.4
Ownership
For profit - Corporation
Provider Type
Medicare
County
Hamilton
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health4/5
Staffing4/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Indiana Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.43 | 0.68 | +0.75 |
| Total Nurse Hours per Resident per Day | 6.30 | 3.73 | +2.57 |
| CMS Staffing Rating | 4/5 | 2.6/5 | - |
| Nursing Staff Turnover | 73.7% | 45.9% | - |
Health Citation History
12 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-02-12 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2025-06-02 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | D – Moderate Harm Potential |
| 2025-06-02 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2025-03-07 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D – Moderate Harm Potential |
| 2025-03-07 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-03-07 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-03-07 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-03-07 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2025-03-07 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | D – Moderate Harm Potential |
| 2024-04-05 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-04-05 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-04-05 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
Fire Safety Citation History
27 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-02-12 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2026-02-12 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2026-02-12 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2026-02-12 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | E – Moderate Harm Potential |
| 2026-02-12 | Services Deficiencies | Have elevators that firefighters can control in the event of a fire. | E – Moderate Harm Potential |
| 2025-03-07 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-03-07 | Smoke Deficiencies | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | F – Moderate Harm Potential |
| 2025-03-07 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2025-03-07 | Smoke Deficiencies | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F – Moderate Harm Potential |
| 2025-03-07 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | F – Moderate Harm Potential |
| 2025-03-07 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2025-03-07 | Services Deficiencies | Have elevators that firefighters can control in the event of a fire. | F – Moderate Harm Potential |
| 2025-03-07 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure that testing and maintenance of electrical equipment is performed. | F – Moderate Harm Potential |
| 2025-03-07 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | F – Moderate Harm Potential |
| 2025-03-07 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2025-03-07 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2025-03-07 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2025-03-07 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | E – Moderate Harm Potential |
| 2025-03-07 | Emergency Preparedness Deficiencies | Include a process for Emergency Preparedness collaboration. | C – Minimal Harm Potential |
| 2025-03-07 | Emergency Preparedness Deficiencies | Provide emergency officials' contact information. | C – Minimal Harm Potential |
| 2025-03-07 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | C – Minimal Harm Potential |
| 2024-04-05 | Emergency Preparedness Deficiencies | Implement emergency and standby power systems. | F – Moderate Harm Potential |
| 2024-04-05 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-04-05 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-04-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-04-05 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2024-04-05 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | C – Minimal Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-03-27 | Payment Denial | - | 6 days starting 2025-06-27 |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the CARMEL area at no cost.
Find Safe, Vetted Facilities Near CARMEL
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.