Inspection Reports for Silver Birch of Hammond

IN, 46320

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Inspection Report Complaint Investigation Census: 111 Deficiencies: 0 Apr 10, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00446352, IN00447572, and IN00448582 at Silver Birch of Hammond.
Findings
No deficiencies related to the allegations in complaints IN00446352, IN00447572, and IN00448582 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of these complaints.
Complaint Details
Complaints IN00446352, IN00447572, and IN00448582 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 111
Employees Mentioned
NameTitleContext
Suzanne WilliamsDirector of Long-Term CareNamed in relation to the Plan of Correction for the complaint survey
Neysa Holman StewartHFASigned the Plan of Correction letter
Inspection Report Complaint Investigation Census: 113 Deficiencies: 0 Oct 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443612.
Findings
No deficiencies related to the allegations in Complaint IN00443612 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00443612 was investigated and found to have no related deficiencies; the complaint was not substantiated.
Inspection Report Complaint Investigation Census: 112 Deficiencies: 4 Aug 28, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00433138, IN00438844, and IN00441212.
Findings
The facility was found deficient in ensuring service plans were reviewed and revised appropriately for 5 of 8 residents, medications were properly signed out in the Medication Administration Record for 1 of 8 residents, insulin pens were not labeled correctly, and clinical records were incomplete or inaccurate related to medication and treatment orders and documentation.
Complaint Details
Complaint IN00433138 resulted in state deficiencies cited at R217 and R243. Complaints IN00438844 and IN00441212 had no deficiencies related to the allegations.
Deficiencies (4)
Description
Failed to ensure service plans were reviewed and revised as appropriate for 5 of 8 resident records reviewed.
Failed to ensure medications administered to the resident were signed out in the Medication Administration Record after completion for 1 of 8 residents.
Failed to label insulin pens with resident's name, physician's name, and dosage instructions for multiple residents.
Failed to maintain clinical records that were complete and accurately documented related to medication and treatment orders, medication availability, and documentation of insulin administration for 1 of 8 resident records reviewed.
Report Facts
Residents with deficient service plans: 5 Residents reviewed for medications: 8 Dates with missing medication sign-out: 19 Insulin pens unlabeled: 8 Audit duration for corrective actions: 12
Employees Mentioned
NameTitleContext
Neysa Holman StewartExecutive DirectorSigned the Plan of Correction letter.
Brenda BurokerDirector of Long-Term Care, Indiana Department of HealthRecipient of the Plan of Correction letter.
Director of NursingInterviewed regarding deficiencies in service plans and medication administration.
Director of Health WellnessResponsible for re-education of nursing staff and auditing corrective actions.
Inspection Report Complaint Investigation Census: 117 Deficiencies: 1 Feb 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426989 regarding clinical record documentation related to incidents between residents.
Findings
The facility failed to ensure clinical records were complete and accurately documented follow-up after incidents between residents for 2 of 3 residents reviewed. Documentation was missing regarding the residents' well-being and follow-up assessments after altercations.
Complaint Details
Complaint IN00426989 was substantiated with a state deficiency cited at R0349 related to clinical record documentation deficiencies.
Deficiencies (1)
Description
Failed to ensure clinical records were complete and accurately documented related to follow-up documentation after incidents between residents with or without injury for 2 of 3 residents reviewed.
Report Facts
Residential Census: 117 Date Survey Completed: Feb 22, 2024
Employees Mentioned
NameTitleContext
Neysa Holman StewartExecutive DirectorNamed as facility representative and signatory on the report
Brenda BurokerDirector of Long-Term CareNamed in plan of correction correspondence
Inspection Report Complaint Investigation Census: 123 Deficiencies: 5 Aug 17, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00411306.
Findings
No deficiencies were cited related to the complaint allegations. Deficiencies were found related to failure to notify physician of medication hold, environmental cleanliness and repair issues, resident smoking in room, insulin pen priming, and incomplete clinical records documentation.
Complaint Details
Complaint IN00411306 was investigated and no deficiencies related to the allegations were cited.
Deficiencies (5)
Description
Failed to ensure the Physician was notified of blood pressure medication being held for 1 of 6 records reviewed (Resident 8).
Failed to maintain an environment that was clean and in good repair related to marred walls, marred doors, stained carpet, holes in doors, dusty ceiling vents, dirty floors, and loose cabinets for 2 of 4 units (1st and 4th floors).
Failed to ensure residents did not smoke in their rooms for 1 of 6 rooms observed (Resident 6).
Failed to ensure insulin pens were primed before use for 1 of 1 insulin injections observed (Resident 10).
Failed to maintain clinical records that were complete and accurately documented related to treatment orders, medication use, oxygen orders, and discharge information for 5 of 6 records reviewed (Residents 2, 8, 9, 3, and 4).
Report Facts
Residential Census: 123 Survey dates: August 16 and 17, 2023 Medication doses held: 2 Insulin units administered: 4 Number of residents with incomplete clinical records: 5
Employees Mentioned
NameTitleContext
Brenda BurokerDirector of Long-Term Care, Indiana Department of HealthRecipient of the Plan of Correction letter.
Neysa Holman StewartHealth Facility Administrator (HFA)Signed the Plan of Correction and responsible for corrective actions.
LPN 1Observed administering insulin without priming the insulin pen.
Wellness DirectorInterviewed regarding medication holds, insulin administration, oxygen orders, and clinical record deficiencies.
AdministratorInterviewed regarding environmental deficiencies and resident smoking incident.
QMA 1Interviewed regarding resident oxygen use.
Inspection Report Complaint Investigation Census: 114 Deficiencies: 0 Jun 15, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00400153.
Findings
No deficiencies related to the allegations were cited. Silver Birch of Hammond was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00400153.
Complaint Details
Investigation of Complaint IN00400153 found no deficiencies related to the allegations.
Inspection Report Complaint Investigation Census: 104 Deficiencies: 2 Jan 10, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00390158, IN00391087, and IN00395018) at Silver Birch of Hammond.
Findings
The investigation substantiated all three complaints. No deficiencies were cited for complaints IN00390158 and IN00391087. Deficiencies related to sanitation and fire/safety standards were cited for complaint IN00395018, specifically regarding unsanitary conditions and smoking violations in a resident's apartment.
Complaint Details
Complaint IN00390158 - Substantiated with no deficiencies cited. Complaint IN00391087 - Substantiated with no deficiencies cited. Complaint IN00395018 - Substantiated with state deficiencies cited at R0144 and R0147 related to sanitation and smoking violations.
Deficiencies (2)
Description
Facility failed to maintain a sanitary environment related to food and fluid cartons, dirt, carpet stains, toilet stains, and trash on the floor in a resident's apartment (Resident G).
Facility failed to comply with fire and safety standards related to a resident smoking in his apartment, including cigarette butts and ashes found on the floor (Resident G).
Report Facts
Residential Census: 104
Employees Mentioned
NameTitleContext
Neysa StewartHFASigned as Laboratory Director's or Provider/Supplier Representative.
Brenda BurokerDirector of Long-Term CareNamed in Plan of Correction correspondence.
Inspection Report Complaint Investigation Census: 115 Deficiencies: 1 Sep 14, 2022
Visit Reason
This visit was conducted for the investigation of Complaints IN00377635 and IN00379510. Complaint IN00377635 was unsubstantiated due to lack of evidence, while Complaint IN00379510 was substantiated with related state deficiencies cited.
Findings
The facility failed to ensure clinical records were complete related to the lack of documentation of a fall, assessment of the resident, or transfer to the hospital for one of three residents reviewed for falls (Resident B). There was no documentation in the clinical record regarding the fall or hospital transfer.
Complaint Details
Complaint IN00377635 was unsubstantiated due to lack of evidence. Complaint IN00379510 was substantiated with state deficiencies cited at R0349.
Deficiencies (1)
Description
Failed to ensure clinical records were complete related to lack of documentation of a fall, assessment, or hospital transfer for Resident B.
Report Facts
Residential Census: 115 Date by which systemic corrections will be completed: Oct 7, 2022
Employees Mentioned
NameTitleContext
Brenda BurokerDirector of Long-Term CareNamed in Plan of Correction correspondence
Neysa Holman StewartHFASigned Plan of Correction

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