Inspection Reports for Silver Birch of Mishawaka
3630 HICKORY ROAD, MISHAWAKA, IN, 46545
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 10, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving food safety, medication management, infection control, and residents’ rights, with some substantiated complaints citing issues such as failure to honor a resident’s choice of physician and medication administration errors. Complaint investigations were mostly unsubstantiated, with only a few substantiated complaints that did not result in enforcement actions or fines listed in the available reports. There were no enforcement actions, fines, or license suspensions noted in the reports. The facility’s inspection history shows improvement over time, with the most recent visits indicating compliance with state regulations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
Date: Jul 10, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00462549.
Complaint Details
Complaint IN00462549 was investigated and found to have no related deficiencies; the complaint was not substantiated.
Findings
No deficiencies related to the allegations in Complaint IN00462549 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Date: Jun 19, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455036.
Complaint Details
Complaint IN00455036 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Renewal
Census: 90
Deficiencies: 3
Date: Jan 16, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on January 15 and 16, 2025, to assess compliance with state regulations.
Findings
The facility was found deficient for failing to ensure a yearly inspection of the heating and ventilation system, and for food safety violations including undated food items and improper food serving techniques. Corrective actions and plans for monitoring compliance were documented.
Deficiencies (3)
Failed to ensure a yearly inspection was performed on the heating and ventilation system.
Failed to store food under sanitary conditions related to undated food in the kitchen preparation area.
Failed to serve food in a sanitary manner, with staff placing thumbs on the eating surface of plates.
Report Facts
Residents affected: 90
Undated food items observed: 12
Residents served improperly: 9
Residents in dining room observed: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Welch | Executive Director | Named as contact and signatory on the report |
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Date: Dec 16, 2024
Visit Reason
This visit was conducted for the investigation of four complaints: IN00447799, IN00446380, IN00444499, and IN00444094.
Complaint Details
Complaints IN00447799, IN00446380, IN00444499, and IN00444094 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with applicable regulations regarding these complaints.
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Date: Sep 4, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00440945, IN00440272, and IN00436946 at Silver Birch of Mishawaka.
Complaint Details
Investigation of Complaints IN00440945, IN00440272, and IN00436946 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00440945, IN00440272, and IN00436946 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 101
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Jun 6, 2024
Visit Reason
This visit was for the Investigation of Complaints IN00433249 and IN00431358.
Complaint Details
Investigation of Complaints IN00433249 and IN00431358 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00433249 and IN00431358 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 112
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 1
Date: Mar 7, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00429653, IN00429494, and IN00426578 at Silver Birch of Mishawaka.
Complaint Details
Complaints IN00429653 and IN00429494 were substantiated with state deficiencies cited at R0035. Complaint IN00426578 had no deficiencies related to the allegations.
Findings
The facility failed to honor the right of a resident (Resident F) to choose their own attending physician by canceling an appointment made at the resident's request with a physician outside the facility. Two complaints were substantiated with deficiencies cited, while one complaint had no deficiencies related to the allegations.
Deficiencies (1)
Facility failed to honor the right of a resident to choose their own attending physician, related to canceling an appointment made at the resident's request with a physician outside the facility.
Report Facts
Residential Census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Dailey | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative |
Inspection Report
Renewal
Census: 112
Deficiencies: 7
Date: Jan 18, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on 1/17/2024 and 1/18/2024 to assess compliance with state regulations.
Findings
The facility was found deficient in several areas including failure to obtain semi-annual weights and medication self-administration assessments, incomplete service plan signatures, improper food labeling and sanitation in the kitchen, unsecured medications in resident rooms and medication storage areas, lack of infection control logs, and missing annual health assessments for some residents.
Deficiencies (7)
Failed to ensure a weight was obtained semi-annually and failed to complete a self-administration of medication assessment on admission for a resident who self-administers medications.
Failed to ensure service plans were signed by the resident or their representative for 3 of 7 residents reviewed.
Failed to ensure food was labeled, dated, stored in a sanitary manner, and kitchen equipment was clean in the main kitchen.
Failed to secure medications appropriately in a resident's room for 1 of 4 residents who self-administer medications.
Failed to store medications in a locked location for 1 of 2 medication storage rooms observed.
Failed to maintain an infection control program related to not having an infection control log to monitor infections within the facility.
Failed to ensure infection control measures were in place related to an annual health assessment not completed for 3 of 7 resident records reviewed.
Report Facts
Residential Census: 112
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Natasha Dailey | Executive Director | Named in plan of correction and compliance communication |
| Cook 3 | Mentioned in relation to kitchen sanitation deficiencies | |
| Cook 4 | Mentioned in relation to kitchen sanitation deficiencies | |
| Director of Wellness | Interviewed regarding medication assessments, service plans, and infection control | |
| LPN 2 | Interviewed regarding medication storage |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Date: Dec 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422747.
Complaint Details
Complaint IN00422747 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations 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: 119
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
This visit was conducted for the investigation of three complaints: IN00419480, IN00417699, and IN00419143.
Complaint Details
Complaint IN00419480 - No deficiencies related to the allegations are cited. Complaint IN00417699 - No deficiencies related to the allegations are cited. Complaint IN00419143 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Date: Sep 8, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416422.
Complaint Details
Complaint IN00416422 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations 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: 115
Deficiencies: 0
Date: Aug 22, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00415298 and IN00414981.
Complaint Details
Complaint IN00415298 and Complaint IN00414981 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with applicable regulations regarding these complaints.
Report Facts
Residential Census: 115
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: May 8, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00407886 and IN00403232.
Complaint Details
Complaint IN00407886 and IN00403232 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with the relevant regulations.
Report Facts
Residential Census: 112
Inspection Report
Re-Inspection
Census: 113
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the State Residential Licensure Survey and Investigation of Complaint IN00399126 completed on 2023-01-26, conducted in conjunction with PSRs to Investigations of Complaints IN00402391 and IN00402722 completed on 2023-03-02.
Complaint Details
Complaint IN00399126 was corrected as of this visit.
Findings
Silver Birch of Mishawaka was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the State Residential Licensure Survey and the Investigation of Complaint IN00399126.
Report Facts
Residential Census: 113
Inspection Report
Follow-Up
Census: 113
Deficiencies: 0
Date: Apr 11, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00402391 and IN00402722 completed on 3/2/2023, conducted in conjunction with a PSR to the State Residential Licensure Survey and Investigation of Complaint IN00399126 completed on 1/26/2023.
Complaint Details
Complaint IN00402391 - Corrected; Complaint IN00402722 - Corrected
Findings
Silver Birch of Mishawaka was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the Investigation of Complaints IN00402391 and IN00402722, and the PSR to the State Residential Licensure Survey.
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 4
Date: Mar 1, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00401491, IN00402391, and IN00402722) regarding quality of care and residents' rights at Silver Birch of Mishawaka.
Complaint Details
Complaint IN00401491 had no state residential findings related to the allegations. Complaint IN00402391 and IN00402722 had state residential findings cited at R0036 and R0243 respectively.
Findings
The facility was found deficient in timely treatment of a urinary tract infection and removal of staples for two residents, as well as failures in medication administration including missed insulin doses and improper medication documentation. Some complaints were substantiated with cited deficiencies, while one complaint had no findings.
Deficiencies (4)
Failure to provide timely treatment for a urinary tract infection (Resident F).
Failure to remove staples timely and document staple care (Resident E).
Failure to administer insulin and proper medication documentation (Residents D and C).
Failure to immediately consult resident's physician and legal representative upon significant decline or need to alter treatment.
Report Facts
Residential Census: 114
Colony forming units: 100000
Medication administration missed: 1
Staples observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacy DeMeester | Executive Director | Signed the report and provided information about policies. |
| Senior Clinical Advisor | Interviewed regarding timeliness of treatment and staple removal. | |
| Qualified Medication Aide (QMA) 1 | Interviewed about medication administration and staple presence. | |
| Qualified Medication Aide (QMA) 4 | Reported Resident D's complaint about missed insulin. | |
| Agency Licensed Practical Nurse (LPN) 7 | Interviewed about insulin administration and medication documentation. |
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 9
Date: Jan 23, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00399165, IN00399126, IN00398640, IN00397632 and IN00395492.
Complaint Details
Complaint IN00399126 substantiated with state residential findings cited at R039; Complaint IN00399165, IN00398640, IN00397632 unsubstantiated; Complaint IN00395492 substantiated with no state residential findings related to allegations.
Findings
The facility had multiple deficiencies including failure to investigate medication concerns for some residents, failure to conduct fire drills with local fire department every six months, lack of yearly HVAC inspection, lack of oxygen orders for a resident, improper PRN medication authorization documentation, unsanitary food service conditions, medication availability issues, lack of pharmacist medication reviews, and incomplete emergency information files.
Deficiencies (9)
Failed to investigate medication concerns related to 2 residents (Residents C and H).
Failed to conduct fire and disaster drill in conjunction with local fire department every six months.
Failed to ensure yearly inspection of heating and ventilation system.
Failed to ensure resident with oxygen had physician orders for oxygen.
Failed to follow policy for Qualified Medication Aides regarding authorization and documentation for PRN medications for 2 residents (Residents J and L).
Failed to ensure food was prepared and served in a clean and sanitized manner; multiple sanitation issues noted in kitchen and food service areas.
Failed to ensure medications were available for Resident H receiving narcotic pain medication.
Failed to ensure pharmacy completed medication reviews for 7 residents (A, B, C, D, F, G, J).
Failed to ensure emergency information files contained all required information including hospital preference for 7 residents (A, B, C, D, F, G, J).
Report Facts
Survey dates: January 23, 24, 25 and 26, 2023
Residential Census: 112
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stacy DeMeester | Executive Director | Signed report and mentioned in plan of correction |
| QMA 5 | Mentioned in medication availability and narcotic medication handling | |
| Employee 7 | Mentioned in medication availability and narcotic medication handling | |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration, pharmacy reviews, and emergency information files |
| Environmental Service Manager | Interviewed regarding HVAC and fire drill deficiencies | |
| Dietary Cook, Employee 8 | Observed during food service sanitation deficiencies | |
| Employee 9 | Observed during food service sanitation deficiencies | |
| Food Service Supervisor | Observed during food service sanitation deficiencies |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Date: Aug 25, 2022
Visit Reason
This visit was for the investigation of complaints IN00388073, IN00387684, and IN00386664.
Complaint Details
Complaint IN00388073 - Substantiated with no state residential findings cited. Complaint IN00387684 - Substantiated with no state residential findings cited. Complaint IN00386664 - Unsubstantiated due to lack of evidence.
Findings
Complaints IN00388073 and IN00387684 were substantiated but no state residential findings related to the allegations were cited. Complaint IN00386664 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Report Facts
Residential Census: 107
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