Inspection Report Summary
The most recent inspection on April 24, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mix of compliance and some deficiencies, including issues with resident care such as medication errors and verbal abuse, as well as staffing and monitoring concerns noted in 2023. Complaint investigations were generally unsubstantiated except for one substantiated verbal abuse incident in late 2023, which led to staff termination; no fines or enforcement actions were listed in the available reports. Life safety inspections mostly found the facility in compliance, with one prior citation for missing exit signage that was later resolved. The overall trend suggests improvement, with recent inspections showing compliance following earlier deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
110 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457384.
Complaint Details
Complaint IN00457384 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census bed type: 110
Census bed type - SNF: 5
Census bed type - Residential: 75
Census bed type - NCC: 30
Census payor type - Medicare: 5
Census payor type - Other: 30
Census payor type - Total: 35
Inspection Report
Complaint Investigation
Census: 75
Deficiencies: 0
Date: Nov 14, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442610.
Complaint Details
Complaint IN00442610 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00442610 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Report Facts
Residential Census: 75
Inspection Report
Life Safety
Census: 8
Capacity: 8
Deficiencies: 0
Date: Aug 20, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is fully sprinklered with a fire alarm system and smoke detection in all required areas.
Report Facts
Certified beds: 8
Census: 8
Inspection Report
Renewal
Census: 106
Deficiencies: 0
Date: Aug 8, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a Non-Certified Comprehensive Survey and a State Residential Licensure Survey conducted on August 5-8, 2024.
Findings
The Barrington of Carmel was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Recertification and State Licensure Survey.
Report Facts
Census Bed Type Total: 106
Census Payor Type Total: 8
SNF Census: 8
Residential Census: 68
Non-Certified Comprehensive Census: 30
Medicare Census: 6
Other Payor Census: 2
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 8, 2024
Visit Reason
The document is an annual inspection report for Barrington of Carmel nursing home, documenting the results of the survey completed on 08/08/2024.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Re-Inspection
Census: 68
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the unrelated deficiency cited during the Investigation of Complaint IN00435083 completed on June 11, 2024.
Findings
The Barrington of Carmel was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to the unrelated deficiency cited during the Investigation of Complaint IN00435083.
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Date: Jun 11, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435083.
Complaint Details
Complaint IN00435083 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. However, unrelated deficiencies were cited at R0052. The facility was found to be in compliance with relevant regulations regarding the complaint.
Report Facts
Census Bed Type - SNF: 6
Census Bed Type - Residential: 69
Census Bed Type - NCC: 29
Total Census: 104
Census Payor Type - Medicare: 2
Census Payor Type - Other: 4
Total Census Payor: 6
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Date: Dec 6, 2023
Visit Reason
This visit was for the investigation of Complaint IN00421930. The complaint allegations were not substantiated, but unrelated deficiencies were cited during the survey conducted on December 5 and 6, 2023.
Complaint Details
Complaint IN00421930 was investigated with no deficiencies related to the allegations cited. The verbal abuse incident involved QMA 1 verbally threatening Resident B and was substantiated by video evidence. QMA 1 was terminated. The medication error involved Resident C receiving Carbidopa-Levodopa-Entacapone instead of Carbidopa-Levodopa, leading to hospitalization.
Findings
The facility failed to ensure a resident was free from verbal abuse after a staff member verbally threatened him. Additionally, the facility failed to ensure the correct medication was administered to a resident, resulting in hospitalization due to medication error.
Deficiencies (2)
Facility failed to ensure a resident was free from verbal abuse after a staff member verbally threatened him with harm.
Facility failed to ensure the correct medication was administered to a resident who exhibited symptoms not typical for him after receiving the incorrect medication.
Report Facts
Residential Census: 50
Medication doses received: 17
Medication doses received: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| QMA 1 | Qualified Medication Aide | Named in verbal abuse finding and termination for verbally threatening Resident B |
| Molly Vissers | Associate Executive Director | Signed the report |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 21, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on June 9, 2023.
Findings
The Barrington of Carmel was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Life Safety
Census: 37
Capacity: 22
Deficiencies: 1
Date: Jul 10, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements due to failure to properly mark two doors leading outside as non-exits, which could confuse residents, staff, and visitors.
Deficiencies (1)
Failed to ensure 2 of 2 doors to the outside of the facility were not mistaken as a facility exit due to lack of 'NO EXIT' signage.
Report Facts
Certified beds: 22
Census: 37
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Molly Vissers | Associate Executive Director | Signed the report. |
| Plant Operations Director | Interviewed regarding exit signage deficiency; placed permanent 'NOT AN EXIT' signs on affected doors. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 10, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 07/10/23.
Findings
The Barrington of Carmel was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Annual Inspection
Census: 52
Capacity: 88
Deficiencies: 4
Date: Jun 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a Non-Certified Comprehensive Survey and a State Residential Licensure Survey conducted on June 7, 8, and 9, 2023.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents at the same table were served simultaneously, failure to notify the physician of significant weight loss in a resident, insufficient registered nurse coverage for certain days, and inadequate monitoring of antipsychotic medication side effects including EPS. The facility was found to be in compliance with State Residential Licensure requirements.
Deficiencies (4)
Failed to ensure residents sitting at the same table were all served before assisting other residents for 12 of 17 residents observed for dining.
Failed to notify the medical doctor about a greater than 5% weight loss in 3 days for 1 of 2 residents reviewed for nutrition.
Failed to ensure a Registered Nurse was in the facility for 8 hours during a 24-hour period for 2 days of the second quarter reviewed for sufficient staffing.
Failed to ensure staff knew how to monitor residents for extrapyramidal side effects (EPS) caused by antipsychotic medications for 2 of 5 residents reviewed for unnecessary medications.
Report Facts
Census: 52
Total Capacity: 88
Residents observed for dining: 17
Residents affected by dining deficiency: 12
Weight loss percentage: 5.4
Days without RN coverage: 2
Dates without RN coverage: 12
Psychotropic medication monitoring period: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kara Owen | Executive Director | Signed the inspection report |
| LPN 5 | Named in monitoring antipsychotic medication side effects deficiency | |
| LPN 6 | Named in monitoring antipsychotic medication side effects deficiency | |
| Certified Nursing Assistant (CNA 2) | Interviewed regarding dining service | |
| Certified Nursing Assistant (CNA 3) | Interviewed regarding dining service | |
| Server 4 | Interviewed regarding dining service | |
| Assistant Director of Nursing (ADON) | Interviewed regarding weight loss and RN coverage | |
| Director of Nursing (DON) | Interviewed regarding RN coverage and staffing |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 9, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, nutrition, staffing, and medication management at Barrington of Carmel nursing home.
Findings
The facility was found deficient in several areas including failure to serve residents at the same time during meals, failure to notify the physician of significant weight loss in a resident, failure to ensure registered nurse coverage for required hours on certain days, and failure to properly monitor residents for extrapyramidal side effects (EPS) related to antipsychotic medications.
Deficiencies (4)
Failed to ensure residents sitting at the same table were all served before assisting other residents for 12 of 17 residents observed for dining.
Failed to notify the MD about a greater than 5% weight loss in 3 days for 1 of 2 residents reviewed for nutrition.
Failed to ensure a Registered Nurse was in the facility for 8 hours during a 24-hour period for 2 days of the second quarter reviewed for sufficient staffing.
Failed to ensure staff knew how to monitor residents for serious side effects of EPS caused by antipsychotic medications for 2 of 5 residents reviewed for unnecessary medications.
Report Facts
Residents observed for dining: 17
Weight loss percentage: 5.4
Days without RN coverage: 2
Dates without licensed nurse coverage: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 5 | Licensed Practical Nurse | Named in medication side effect monitoring deficiency; did not know what EPS was despite signing MAR. |
| LPN 6 | Licensed Practical Nurse | Named in medication side effect monitoring deficiency; did not know what EPS was despite signing MAR. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding RN staffing deficiencies and scheduling. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding weight loss notification and re-weighing resident. |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding antipsychotic medication side effect monitoring and AIMS testing. |
Inspection Report
Complaint Investigation
Census: 91
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00405647.
Complaint Details
Complaint IN00405647 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00405647 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 91
Census Bed Type SNF: 17
Census Bed Type Residential: 56
Census Bed Type NCC: 18
Census Payor Type Medicare: 5
Census Payor Type Other: 30
Census Payor Type Total: 35
Inspection Report
Life Safety
Census: 34
Capacity: 48
Deficiencies: 0
Date: Aug 1, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/21/22 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The Barrington of Carmel was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with a fire alarm system and smoke detection throughout.
Report Facts
Facility capacity: 48
Census: 34
Inspection Report
Deficiencies: 1
Date: Jun 15, 2022
Visit Reason
The inspection was conducted to assess compliance with privacy regulations regarding residents' personal and medical records during assessments.
Findings
The facility failed to ensure a resident received privacy during an assessment, as a Psychiatric Nurse Practitioner interviewed a resident in the dining room in the presence of others, which was deemed inappropriate.
Deficiencies (1)
Failed to ensure a resident received privacy during an assessment; resident was interviewed in a public dining room area.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Psychiatric Nurse Practitioner | Observed interviewing resident in dining room during assessment | |
| Director of Nursing | Interviewed regarding the Nurse Practitioner's inappropriate assessment location |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 15, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on June 15, 2022.
Findings
The Barrington of Carmel was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
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