Inspection Report Summary
The most recent inspection on April 10, 2025, found no deficiencies related to the complaints investigated. Earlier inspections showed a pattern of deficiencies primarily involving incomplete or inaccurate clinical record documentation, medication administration issues, and environmental cleanliness or safety concerns such as smoking violations. Several complaint investigations were substantiated with related citations, particularly around clinical documentation and sanitation, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaints investigated in recent years were unsubstantiated or found without related deficiencies. The facility’s record shows some improvement in the most recent inspection after a period of mixed findings.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
111 residents
Based on a April 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 0
Date: Apr 10, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00446352, IN00447572, and IN00448582 at Silver Birch of Hammond.
Complaint Details
Complaints IN00446352, IN00447572, and IN00448582 were investigated and found to have no deficiencies related to the allegations.
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.
Report Facts
Residential Census: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzanne Williams | Director of Long-Term Care | Named in relation to the Plan of Correction for the complaint survey |
| Neysa Holman Stewart | HFA | Signed the Plan of Correction letter |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Date: Oct 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00443612.
Complaint Details
Complaint IN00443612 was investigated and found to have no related deficiencies; the complaint was not substantiated.
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.
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 4
Date: Aug 28, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00433138, IN00438844, and IN00441212.
Complaint Details
Complaint IN00433138 resulted in state deficiencies cited at R217 and R243. Complaints IN00438844 and IN00441212 had no deficiencies related to the allegations.
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.
Deficiencies (4)
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
| Name | Title | Context |
|---|---|---|
| Neysa Holman Stewart | Executive Director | Signed the Plan of Correction letter. |
| Brenda Buroker | Director of Long-Term Care, Indiana Department of Health | Recipient of the Plan of Correction letter. |
| Director of Nursing | Interviewed regarding deficiencies in service plans and medication administration. | |
| Director of Health Wellness | Responsible for re-education of nursing staff and auditing corrective actions. |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 1
Date: Feb 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00426989 regarding clinical record documentation related to incidents between residents.
Complaint Details
Complaint IN00426989 was substantiated with a state deficiency cited at R0349 related to clinical record documentation deficiencies.
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.
Deficiencies (1)
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
| Name | Title | Context |
|---|---|---|
| Neysa Holman Stewart | Executive Director | Named as facility representative and signatory on the report |
| Brenda Buroker | Director of Long-Term Care | Named in plan of correction correspondence |
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 5
Date: Aug 17, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00411306.
Complaint Details
Complaint IN00411306 was investigated and no deficiencies related to the allegations were cited.
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.
Deficiencies (5)
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
| Name | Title | Context |
|---|---|---|
| Brenda Buroker | Director of Long-Term Care, Indiana Department of Health | Recipient of the Plan of Correction letter. |
| Neysa Holman Stewart | Health Facility Administrator (HFA) | Signed the Plan of Correction and responsible for corrective actions. |
| LPN 1 | Observed administering insulin without priming the insulin pen. | |
| Wellness Director | Interviewed regarding medication holds, insulin administration, oxygen orders, and clinical record deficiencies. | |
| Administrator | Interviewed regarding environmental deficiencies and resident smoking incident. | |
| QMA 1 | Interviewed regarding resident oxygen use. |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Date: Jun 15, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00400153.
Complaint Details
Investigation of Complaint IN00400153 found no deficiencies related to the allegations.
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.
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 2
Date: Jan 10, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00390158, IN00391087, and IN00395018) at Silver Birch of Hammond.
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.
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.
Deficiencies (2)
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
| Name | Title | Context |
|---|---|---|
| Neysa Stewart | HFA | Signed as Laboratory Director's or Provider/Supplier Representative. |
| Brenda Buroker | Director of Long-Term Care | Named in Plan of Correction correspondence. |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 1
Date: 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.
Complaint Details
Complaint IN00377635 was unsubstantiated due to lack of evidence. Complaint IN00379510 was substantiated with state deficiencies cited at R0349.
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.
Deficiencies (1)
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
| Name | Title | Context |
|---|---|---|
| Brenda Buroker | Director of Long-Term Care | Named in Plan of Correction correspondence |
| Neysa Holman Stewart | HFA | Signed Plan of Correction |
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