Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Retreat At The Stratford, The during CMS and state inspections, most recent first.
Failure to Notify Physician of Repeated Weight Gains: A resident with CHF, CKD, COPD, asthma, and SOB had a care plan and MD order for daily weights and notification for overnight gains of 2 lbs or more. The record showed multiple weight increases meeting that threshold over several days, but the CSN could not find documentation that the MD was notified, and staff stated they did not indicate they had called about the repeated gains.
A resident with a history of a left humerus fracture and cirrhosis was found with medications left at the bedside for self-administration without an IDT assessment, physician order, or care plan in place. An LPN was unaware of any assessment, and the Care Services Administrator confirmed the required documentation was missing, contrary to facility policy.
Two residents experienced verbal abuse and intimidation from a CNA, including accusations, rude behavior, and physical restraint. One resident, with significant cardiac conditions and intact cognition, was left shaken after the CNA grabbed her wrists, pushed her back into her room, and took her phone when she tried to call for help. Facility policies guaranteeing freedom from abuse were not upheld.
The facility failed to notify physicians and document orders for advanced directives for three residents. One resident's DNR status was not documented until 3.5 months after admission, another's was delayed by 15 days, and a third resident had no code status order. Interviews confirmed the facility's policy was not followed.
A resident with heart failure and other conditions experienced significant weight loss, but the facility failed to update the care plan within the required timeframe. Despite a dietician's recommendation for nutritional supplements, the care plan was not modified as per policy, as confirmed by interviews with facility staff.
A resident with a history of diabetes, hypertension, and stroke was observed with multiple bruises on both arms, but the facility failed to document and monitor these skin issues as required by their care plan and policy. Despite a physician's order for aspirin, which can increase bruising risk, only one bruise was recorded in the resident's clinical record. Interviews with staff confirmed the need for documentation and monitoring, which was not performed.
The facility failed to ensure proper reconciliation of narcotic counts, as evidenced by missing signatures from on-coming and off-going nurses on narcotic count sheets. Observations and interviews confirmed that staff did not consistently sign off on the narcotic counts, despite facility policy requiring this practice. Documentation showed multiple instances of missing signatures across several dates.
The facility failed to ensure proper medication storage and labeling, with pills found loose in a cart and an opened Aplisol vial without a date. Additionally, refrigerator temperatures were inconsistently logged, missing numerous entries. RN 1 and the Corporate Support Nurse acknowledged these lapses, which violated the facility's medication storage policy.
The facility failed to ensure a recipe was available and followed for pureed foods, affecting two residents on a pureed diet. The Dietary Manager was observed pureeing tuna melt sandwiches without a recipe and using cold milk instead of hot milk, contrary to facility policy. Staff were trained on liquid use during orientation, but no written guidance was available for fill-in staff.
The facility failed to ensure food was distributed under safe sanitary conditions for all 14 residents in the nursing home area. Cook 3 did not take food temperatures before placing meal trays in the cart, handled various surfaces and food items with soiled gloves, and did not wash hands between glove changes, violating the facility's hygiene policy.
The facility failed to ensure ongoing communication with the dialysis center for a resident with ESRD and dependence on dialysis. Multiple instances of incomplete records and missing communication notes were identified from January to April 2024. Despite efforts by the DON and Administrator, the issue remained unresolved.
A facility failed to ensure ordered wound treatments were completed for a resident with a pacemaker, leading to an infection and the need for a pacemaker replacement. Identical clinical notes over a 14-day period indicated a lack of proper monitoring and care.
Failure to Notify Physician of Repeated Weight Gains
Penalty
Summary
The facility failed to ensure the physician was notified of daily weight gains as ordered for Resident 3. The resident’s record showed diagnoses including congestive heart failure, chronic kidney disease, chronic obstructive pulmonary disease, mild persistent asthma with acute exacerbation, and shortness of breath. A care plan dated 10/3/25 identified the resident as at risk for complications related to chronic kidney disease and included monitoring weight and notifying the physician of a significant weight change. A physician’s order dated 10/8/25 directed staff to weigh the resident daily at 6:00 a.m. and notify the physician if there was a weight gain of 2 pounds or more overnight. Resident 3 had multiple recorded weight gains of 2 pounds or more between 1/4/26 and 2/11/26, including gains from 157 to 161 pounds, 157.8 to 162 pounds, 158 to 161 pounds, 156 to 161.12 pounds, 155 to 157 pounds, 157 to 159 pounds, 157 to 161 pounds, 158 to 160 pounds, 158 to 160 pounds, 156 to 161 pounds, 158 to 160 pounds, and 159 to 163.12 pounds. During an interview on 2/11/26, the Clinical Support Nurse stated he could not find documentation of notifications for the weight gains since January, and nurses indicated they were supposed to call the physician with updates or needs but did not indicate they had called regarding the multiple weight gains. The facility policy stated the nurse will notify the resident’s attending physician or physician on call when there has been a specific instruction to notify the physician of changes.
Failure to Assess and Authorize Resident for Self-Administration of Medications
Penalty
Summary
A resident with diagnoses including a left humerus fracture and cirrhosis of the liver was observed with a cup of pills left on her bedside table, which she indicated were her medications left by staff for her to take. The resident stated she would take the pills after eating, and an LPN confirmed that the medications were left at the bedside because the resident wanted to eat first. The LPN was unaware if the resident had been assessed for self-administration of medications and stated she was supposed to stay with residents while they took their medications. Review of the resident's clinical record revealed there was no assessment by the interdisciplinary team (IDT), no physician's order, and no comprehensive care plan authorizing self-administration of medications. The Care Services Administrator confirmed the absence of these required documents. Facility policy requires a Medication Self-Administration Evaluation, physician notification, and an order prior to allowing self-administration, none of which were completed for this resident.
Failure to Protect Residents from Verbal and Physical Abuse by CNA
Penalty
Summary
The facility failed to protect two residents from verbal abuse and intimidation by a certified nursing assistant (CNA). One resident reported that the CNA was cross and impatient, accusing her of intentionally sliding down in bed, which the resident found upsetting. Another resident described the CNA as verbally rude, refusing to assist with moving a bed to retrieve a remote control, and displaying hostile behavior when asked for milk by slamming it down and leaving the room abruptly. Later, the second resident recounted an incident where, after a call light was activated, the CNA raised her voice and sounded belligerent toward the first resident. The second resident, feeling unsafe, attempted to leave the room but was physically restrained by the CNA, who grabbed her wrists and pushed her back into the room. The CNA then took the resident's phone away when she tried to call her son, leaving the resident visibly shaken. The resident reported her fear to a registered nurse (RN), who assured her that the CNA would not return that night. The clinical record for the second resident indicated she was cognitively intact and had significant cardiac diagnoses, including left bundle branch block, atrioventricular block, and atherosclerotic heart disease. Documentation confirmed that the resident was upset and shaken after the altercation, though no physical injuries were observed. The facility's policies guarantee residents the right to be free from all forms of abuse, including verbal and physical abuse, but these rights were not upheld in this instance.
Failure to Document Advanced Directives in Medical Records
Penalty
Summary
The facility failed to ensure that physicians were notified of residents' advanced directives and that appropriate orders were documented in the residents' medical records. This deficiency was identified for three residents. Resident 8 had a POST form indicating a Do Not Resuscitate (DNR) status completed and signed on 11/12/24, but the physician's order was not documented until 3.5 months after admission. Similarly, Resident 63 had a POST form completed on 2/21/25, but the physician's order was not documented until 15 days after admission. Resident 68 did not have any order for code status entered into the medical record. Interviews with the Director of Nursing and the Corporate Support Nurse confirmed that the facility's policy required the notification of the attending physician regarding advanced directives to ensure proper documentation in the medical record. The facility's policy, revised in April 2009, was not followed, leading to the deficiency in documenting the residents' advanced directives in a timely manner.
Failure to Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for a resident who experienced significant weight loss. The resident, diagnosed with heart failure, vitamin deficiency, dysphagia, and anorexia, was noted to have a significant weight loss of 5.7% over 30 days, with further weight loss recorded shortly thereafter. Despite a Registered Dietician's recommendation to administer Ensure Plus twice daily to stabilize the resident's weight, the care plan was not updated within the required 14-day period following the significant weight loss. Interviews with facility staff, including the Clinical Support Nurse and the Director of Nursing, confirmed that the care plan should have been updated within 14 days of the significant weight loss. The facility's policy, which mandates documentation and modification of care plans when goals and objectives are not achieved, was not adhered to in this instance. The Corporate Support Nurse indicated that the facility followed state and federal regulations but had no additional information to provide.
Failure to Document and Monitor Resident's Skin Issues
Penalty
Summary
The facility failed to assess and document skin issues for a resident, identified as Resident 5, who was observed to have multiple bruises on both arms. Despite a care plan initiated in April 2024 indicating the resident was at risk for skin alterations and required complete skin assessments, the clinical record only documented a bruise on the right lateral elbow, with no other skin concerns recorded. The resident's medical history included diabetes mellitus, hypertension, hyperlipidemia, and a history of stroke, and they were on a physician's order for aspirin, which can increase the risk of bruising. Interviews conducted with facility staff, including an LPN and the Corporate Support Nurse, revealed that the bruising should have been documented and monitored on skin sheets. The Corporate Support Nurse confirmed that weekly skin assessments were required to note any discolorations, rashes, wounds, open areas, and dryness, including the characteristics of the areas such as color and size. The facility's policy on resident examination and assessment, last revised in February 2014, also indicated the need for documentation of bruises during physical exams.
Failure to Ensure Proper Narcotic Count Reconciliation
Penalty
Summary
The facility failed to ensure that narcotic count sheets were consistently signed off by both the on-coming and off-going nurses, which is necessary for accurate reconciliation of narcotic counts. During an observation, it was noted that the narcotic book lacked entries showing that the nurses had reconciled the narcotic count and signed the book to confirm the review. Interviews with RN 1 and the Director of Nursing confirmed that staff were expected to sign the narcotic count sheets at each shift change, but this was not consistently done. The facility's documentation revealed multiple instances where signatures were missing for both day and evening shifts across several dates in January and February 2025. Specifically, the January 2025 narcotic count sheet showed missing signatures on several days, and the February 2025 sheet indicated 24 out of 84 missed opportunities for sign-off. A facility policy on controlled substances required that the on-coming and off-going nurses count the controlled medication inventory together at the end of each shift, but this procedure was not followed as evidenced by the missing signatures.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and labeling practices, as observed during a survey. During an inspection of the medication cart, several pills were found outside of their original packaging and loose within the cart. These included a round white oval tablet with an imprint, three small round white tablets, three oval white tablets, one medium round white tablet, and one rectangular white tablet. RN 1, who was present during the observation, indicated that another nurse was responsible for cleaning the cart. Additionally, the facility did not adhere to proper labeling and monitoring protocols for medication storage. An opened bottle of Aplisol, a tuberculosis testing serum, was found in the medication refrigerator without an open date. Furthermore, the facility failed to consistently document the refrigerator temperatures, with numerous dates in January and February missing temperature logs. RN 1 acknowledged that the vial should have been labeled with an open date and that refrigerator temperatures were supposed to be checked and logged nightly. The Corporate Support Nurse confirmed that daily monitoring of refrigerator temperatures was required, as per the facility's medication storage policy.
Failure to Follow Pureed Food Recipe
Penalty
Summary
The facility failed to ensure that a recipe was available and followed for pureed foods, which affected two residents on a pureed diet. During an observation, the Dietary Manager was seen pureeing tuna melt sandwiches without a recipe and using an unmeasured amount of cold milk to thin the food. The Dietary Manager admitted that there were no recipes for pureeing food, including portion sizes or the appropriate thickeners and thinners to use. Staff were trained during orientation on what liquids to use, but there was no written guidance available for staff who might need to fill in for absent team members. The Dietary Manager later created a recipe book, but it was not in place at the time of the observation. The recipe for the pureed tuna melt indicated the use of hot milk, whereas cold milk was used during the preparation. The facility's current policy on pureed diets required the use of measured amounts of hot liquid for cooked foods and cold liquid for cold foods to achieve a smooth consistency. This lack of adherence to established procedures and absence of a recipe at the time of food preparation led to the deficiency.
Failure to Maintain Sanitary Conditions During Food Service
Penalty
Summary
The facility failed to ensure food was distributed under safe sanitary conditions for all 14 residents in the nursing home area. During a lunch meal service observation, it was noted that Cook 3 did not take the temperatures of the food before placing meal trays in the food service cart. Additionally, Cook 3 dropped an alcohol wipe wrapper on the floor, picked it up with gloved hands, and continued to take food temperatures without changing gloves. Cook 3 also handled various surfaces and food items with the same soiled gloves, including meal tickets, dishes, utensils, and hot dog buns, without washing hands between glove changes. The facility's policy on preventing foodborne illness and employee hygiene, dated October 2017, was not followed. The policy required employees to wash their hands before coming into contact with any food surface, after handling soiled equipment or utensils, and as often as necessary during food preparation to prevent cross-contamination. The policy also stated that gloves are single-use items and must be discarded after completing a task. These lapses in following proper sanitary practices were observed multiple times during the meal service, leading to potential contamination of the food served to residents.
Failure to Ensure Ongoing Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication for the continuation of care with the dialysis center for a resident with end-stage renal disease (ESRD) and dependence on dialysis. The resident's clinical record indicated a current order for dialysis and a care plan to monitor for complications. However, from January 2024 to April 2024, communication notes were not downloaded into the electronic medical record. Additionally, the dialysis communication binder showed multiple instances of incomplete records, including missing pre-dialysis and post-dialysis assessments on various dates in March and April 2024, as well as missing log pages in January and February 2024. During an interview, the Director of Nursing (DON) and the Administrator acknowledged the ongoing issue with the dialysis center not completing the required communication forms. Despite multiple calls to the dialysis center administrator, the problem remained unresolved. The facility continued to use this dialysis center due to its proximity, and the forms were sent with the resident for every visit. The facility's contract with the dialysis center required the interchange of information necessary for the care of ESRD residents, but this was not consistently achieved.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure ordered wound treatments were completed as prescribed for a resident who had undergone pacemaker implantation. The resident's clinical notes indicated that the wound care instructions were not followed, as there was no documentation of the pacemaker incision site being washed and patted dry daily from the time the order was received until the site became infected. Identical clinical notes were repeatedly entered over a 14-day period, suggesting a lack of proper monitoring and care for the wound site. The resident's condition deteriorated, with the site becoming red, painful, and eventually infected, leading to a fever. The resident was subsequently placed on antibiotics and required a pacemaker replacement due to the infection. The family of the resident expressed concerns about the lack of wound care during a care conference, which led to the facility's acknowledgment of the issue. Interviews with the resident's family and the facility's administrator confirmed that the wound care was not performed as ordered. The facility's documentation and grievance forms further supported the family's claims, indicating that the facility did not routinely monitor the wound site or follow the prescribed wound care regimen. The deficiency was identified as a failure to provide appropriate treatment and care according to the resident's medical orders and needs.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 880 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carmel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Copper Trace Health & Living Community | 1.8 mi | ★★★★★ | 9 | 0 |
| Majestic Care Of Carmel | 2.6 mi | ★★★★★ | 0 | 0 |
| Wellbrooke Of Carmel | 2.6 mi | ★★★★★ | 10 | 0 |
| Barrington Of Carmel, The | 3.4 mi | ★★★★★ | 0 | 0 |
| Hoosier Village | 3.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Retreat At The Stratford, The.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.