01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-02-12 | 1 | 2026-02-12 | 5 |
| Cycle 2 | 2025-03-07 | 8 | 2025-03-07 | 16 |
| Cycle 3 | 2024-04-05 | 3 | 2024-04-05 | 6 |
CMS CCN 1557942026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Retreat At The Stratford, The
2460 Glebe St · Carmel, IN 46032 · Hamilton County
Certified beds18CMS provider file
Recent citation rows39current CMS citation release
Penalty rows1current 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
39 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.
2026-02-12 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-202026-02-12 · FIREK0222Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-03-102026-02-12 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2026-03-102026-02-12 · 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 · 2026-03-102026-02-12 · FIREK0531Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have elevators that firefighters can control in the event of a fire.
Correction field: Deficient, Provider has date of correction · 2026-03-102026-02-12 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2026-03-102025-06-02 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2025-06-16 · complaint2025-06-02 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
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.
Correction field: Past Non-Compliance · 2025-05-25 · complaint2025-03-07 · FIREE0009Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Include a process for Emergency Preparedness collaboration.
Correction field: Deficient, Provider has date of correction · 2025-06-172025-03-07 · FIREE0031Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Provide emergency officials' contact information.
Correction field: Deficient, Provider has date of correction · 2025-06-172025-03-07 · FIREE0039Severity C · widespread; potential for minimal harm
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Correction field: Deficient, Provider has date of correction · 2025-06-172025-03-07 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-022025-03-07 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-022025-03-07 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-04-022025-03-07 · 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 · 2025-04-022025-03-07 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-04-022025-03-07 · HEALTHF0804Severity D · isolated; 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 · 2025-04-022025-03-07 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-06-172025-03-07 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-06-172025-03-07 · FIREK0346Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Correction field: Deficient, Provider has date of correction · 2025-06-172025-03-07 · 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 · 2025-06-172025-03-07 · FIREK0354Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Correction field: Deficient, Provider has date of correction · 2025-06-172025-03-07 · FIREK0355Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2025-06-172025-03-07 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-06-1703 / 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 |
|---|---|---|---|
| 2025-03-27 | Payment Denial | $0 | 6 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- THOMPSON, BENJAMINIndividual · 5% OR GREATER DIRECT OWNERSHIP INTEREST25% · since 01/01/2021
- THOMPSON, DONALDIndividual · 5% OR GREATER DIRECT OWNERSHIP INTEREST50% · since 09/17/2010
- THOMPSON, JOSHUAIndividual · 5% OR GREATER DIRECT OWNERSHIP INTEREST25% · since 01/01/2021
- MAXWELL GROUP, INC.Organization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/10/2010
- MILLER, BRADLEYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/19/2025
- SOLITO, LEOIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2024
- THOMPSON, BENJAMINIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/01/2022
- MAXWELL GROUP, INC.Organization · ADP OF THE SNFNOT APPLICABLE · since 02/01/2025
- MILLER, BRADLEYIndividual · ADP OF THE SNFNOT APPLICABLE · since 02/02/2026
- SOLITO, LEOIndividual · ADP OF THE SNFNOT APPLICABLE · since 02/02/2026
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 hours6.50per resident day
RN hours1.49per resident day
Weekend nurse hours6.05per resident day
Staff turnover76.5%CMS reported field
06 / LOCAL RECORDS
Open the Carmel ledger →Other published facilities nearby
Barrington Of Carmel, The8 beds · CMS overall 5/55 citation rowsBridgewater Healthcare Center120 beds · CMS overall 5/530 citation rowsCarmel Health & Living Community188 beds · CMS overall 2/547 citation rowsMajestic Care Of Carmel94 beds · CMS overall 2/538 citation rowsMcgivney Health Care Center37 beds · CMS overall 2/560 citation rowsRestoracy Of Carmel72 beds · CMS overall 4/541 citation rowsWellbrooke Of Carmel74 beds · CMS overall 3/534 citation rows