Inspection Reports for Silver Birch of Evansville
475 S Governor St, Evansville, IN 47713, United States, IN, 47713
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 14, 2025, found no deficiencies related to the complaints investigated. Earlier inspections showed a pattern of deficiencies primarily involving medication management, including follow-up policies, documentation, and pharmacy services, as well as issues with service plans and medication storage. Complaint investigations occasionally substantiated these medication-related deficiencies, including a notable case in June 2023 where delayed physician notification contributed to a resident developing Stevens-Johnson syndrome. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have made improvements over time, with recent complaint investigations showing compliance and fewer cited deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
94 residents
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Date: Jul 14, 2025
Visit Reason
This visit was conducted for the investigation of three complaints: IN00462261, IN00461776, and IN00460561.
Complaint Details
Complaint IN00462261, IN00461776, and IN00460561 were investigated with no deficiencies related to the allegations 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 relevant regulations.
Report Facts
Residential Census: 94
Inspection Report
Complaint Investigation
Census: 98
Capacity: 98
Deficiencies: 0
Date: Apr 16, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00457606.
Complaint Details
Investigation of Complaint IN00457606 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegation(s) are cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Report Facts
Census Residential: 98
Total Capacity: 98
Census Payor Type Medicaid: 96
Census Payor Type Other: 2
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Date: Feb 27, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452909 and IN00454478. Complaint IN00452909 had no deficiencies related to the allegations, while complaint IN00454478 resulted in state deficiencies related to medication follow-up policies.
Complaint Details
Complaint IN00452909 had no deficiencies related to the allegations. Complaint IN00454478 was substantiated with state deficiencies cited related to medication follow-up.
Findings
The facility failed to ensure a follow-up policy for medications ordered from the pharmacy for one of three residents reviewed for self-administration of medication. Specifically, Resident S experienced a delay in receiving Ozempic due to lack of timely follow-up on medication orders, and the facility lacked a policy for following up on medication orders once faxed to the pharmacy.
Deficiencies (1)
Failed to ensure a follow-up policy for medications ordered from the pharmacy for 1 of 3 residents reviewed for self-administration of medication.
Report Facts
Residential Census: 102
Dates of survey: 2
Medication delay: 11
Medication delay days: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dee Jolly | Administrator | Named in relation to the plan of correction and interview about medication follow-up policy |
| RN 7 | Registered Nurse | Named in relation to medication ordering and self-administration safety screen |
| Director of Nursing | Director of Nursing (DON) | Named in relation to medication ordering and follow-up |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 5
Date: Nov 25, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the investigation of complaints IN00446328 and IN00447740. Complaint IN00446328 resulted in state deficiencies cited, while complaint IN00447740 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00446328 was substantiated with state deficiencies cited related to the allegations. Complaint IN00447740 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' weights were taken or recorded semiannually for 5 of 8 residents, failure to ensure service plans were signed and dated for 7 of 8 residents, improper medication storage and labeling on medication carts, and incomplete documentation of insulin administration and mental health service refusals in clinical records.
Deficiencies (5)
Failed to ensure residents' weights were taken or recorded semiannually for 5 of 8 residents.
Failed to ensure service plans were signed and dated for 7 of 8 residents who received services.
Failed to ensure medications were properly stored and labeled for 3 of 3 medication carts observed.
Failed to ensure medication was labeled in 2 of 3 medication carts reviewed; insulin pens were not labeled.
Failed to ensure documentation was complete for 3 of 3 residents reviewed for insulin and 1 of 4 residents reviewed for mental health screening; insulin administration was not documented and refusal of mental health services was not documented.
Report Facts
Residential Census: 103
Deficiencies cited: 5
Medication counts: 6
Medication counts: 2
Medication counts: 1
Medication counts: 1
Audit frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dee Jolly | Administrator / Executive Director | Named as contact for plan of correction and involved in providing documentation and interviews. |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 1
Date: Sep 17, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00441420, IN00440731, IN00440245, and IN00434344. The investigation focused on allegations related to medication administration and other care concerns.
Complaint Details
Complaints IN00441420 and IN00440245 had state deficiencies related to the allegations cited at R117. Complaints IN00440731 and IN00434344 had no deficiencies related to the allegations. The citation relates specifically to complaints IN00441420 and IN00440245.
Findings
The facility failed to ensure Qualified Medication Aides (QMAs) documented the administration of as needed (PRN) pain medications completely for 2 of 3 residents reviewed. Authorization from a licensed nurse to administer PRN medications was not documented as required by the QMA Scope of Practice. Specific incidents included administration of wrong medication and lack of nurse approval documentation.
Deficiencies (1)
Failure to ensure QMAs documented administration of PRN pain medications completely and obtain nurse authorization as required by QMA Scope of Practice.
Report Facts
Census: 104
Total Capacity: 104
Medicaid Census: 102
Other Payor Census: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dee Jolly | Administrator / Executive Director | Named as contact for plan of correction and facility representative |
| QMA 14 | Qualified Medication Aide | Interviewed regarding PRN medication administration procedures |
| LPN 22 | Licensed Practical Nurse | Provided facility policy titled Qualified Medication Aide Scope of Practice |
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
Date: Mar 18, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00430057 and IN00429055.
Complaint Details
Investigation of Complaint IN00430057 and IN00429055 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00430057 and IN00429055 were cited. The facility was found to be in compliance with applicable regulations.
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 0
Date: Feb 6, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00425877 and IN00427058.
Complaint Details
Complaint IN00425877 - No deficiencies related to the allegations are cited. Complaint IN00427058 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00425877 and IN00427058 were cited. The facility was found to be in compliance with applicable regulations regarding these complaints.
Inspection Report
Follow-Up
Census: 113
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00410698 and IN00410685 completed on June 29, 2023, and was conducted in conjunction with the Investigation of Complaints IN00412759, IN00412579, and IN00412560.
Complaint Details
This visit was related to multiple complaints: IN00410698, IN00410685, IN00412759, IN00412579, and IN00412560. Complaints IN00410698 and IN00410685 were corrected.
Findings
Silver Birch of Evansville was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to Investigation of Complaints IN00410698 and IN00410685. Complaints IN00410698 and IN00410685 were corrected.
Report Facts
Residential Census: 113
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
This visit was for the investigation of complaints IN00412560, IN00412759, and IN00412579, in conjunction with the Post Survey Revisit to Investigation of Complaint IN00410698 and Complaint IN00410685 completed on June 29, 2023.
Complaint Details
Complaints IN00412560, IN00412759, and IN00412579 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited for complaints IN00412560, IN00412759, and IN00412579. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these investigations.
Report Facts
Residential Census: 113
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 1
Date: Jun 29, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00410698 and IN00410685, related to allegations concerning medication side effects and physician notification.
Complaint Details
The investigation was triggered by complaints IN00410698 and IN00410685. The complaints were substantiated with state deficiencies cited at R00242 related to failure to observe and document medication side effects and timely physician notification.
Findings
The facility failed to notify the physician in a timely manner about a resident's adverse reaction to a medication, resulting in the resident developing Stevens-Johnson syndrome. The report details the resident's symptoms, delayed notification, and subsequent treatment and monitoring plans.
Deficiencies (1)
Failure to notify the physician immediately of undesirable effects of medication for Resident F, who developed Stevens-Johnson syndrome after an allergic reaction to clindamycin.
Report Facts
Residential Census: 102
Survey Dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dee Jolly | Executive Director | Contact person for plan of correction and compliance confirmation |
| LPN 1 | Licensed Practical Nurse | Worked weekend when resident had reaction; involved in medication administration and resident interaction |
| Director of Nursing | Director of Nursing (DON) | Queried about the resident's reaction and responsible for physician notification and corrective actions |
| Nurse Practitioner | Nurse Practitioner | Provided medical orders and documented concerns about delayed notification of allergic reaction |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 9
Date: May 19, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00406683 and IN00408321.
Complaint Details
This inspection included investigation of Complaints IN00406683 and IN00408321 with state deficiencies cited related to these complaints.
Findings
The facility was found deficient in multiple areas including failure to conduct fire drills with the local fire department every six months, lack of a nourishment station for supplemental food service, incomplete resident evaluations and service plans, failure to obtain authorization for PRN medications, poor dietary hygiene and cleaning practices, pharmaceutical service deficiencies including medication availability and documentation, and improper medication storage.
Deficiencies (9)
Failed to perform fire drills every six months in conjunction with the local fire department.
Failed to have a nourishment station for supplemental food service separate from the resident's unit.
Failed to ensure thorough assessments for residents were completed and recorded, including weights and self-administration of medication evaluations.
Failed to ensure service plans were reviewed and signed by residents or representatives for 5 of 6 residents reviewed.
Failed to ensure QMAs obtained authorization by a licensed nurse for administration of PRN medications for 4 of 7 resident records reviewed.
Failed to maintain all food preparation and serving areas in accordance with state and local sanitation and safe food handling standards.
Failed to ensure pharmaceutical services were available to provide residents with prescribed medications in accordance with applicable laws for 3 of 5 residents reviewed.
Failed to ensure the consulting pharmacy reviewed drug handling and storage practices, provided consultation, and reported irregularities for 4 of 5 residents reviewed.
Failed to ensure proper storage of medications; a box of labeled and unlabeled pills was found on the floor in the medication storage room.
Report Facts
Survey dates: 3
Resident census: 92
Fire drills required: 12
Fire drills required quarterly: 4
Narcotic pills unaccounted: 30
Medication destruction: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dee Jolly | Executive Director | Named in plan of correction and contact for compliance |
| Director of Nursing (DON) | Interviewed regarding fire drills, medication administration, and policies | |
| Assistant Administrator | Interviewed regarding medication self-administration and pharmacy issues | |
| Qualified Medication Aides (QMAs) | Interviewed regarding medication administration and authorization | |
| Dietary Manager | Observed with improper hair covering and hygiene issues | |
| Pharmacist at contracted pharmacy | Interviewed regarding pharmacy services and audits |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 0
Date: Mar 2, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00397028 and IN00401045.
Complaint Details
Complaint IN00397028 and IN00401045 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.
Report Facts
Residential Census: 94
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 2
Date: Nov 18, 2022
Visit Reason
This visit was for the investigation of multiple complaints (IN00391999, IN00389458, IN00389366, IN00388900, IN00388446, IN00387654, and IN00385445) regarding the facility's medication administration and clinical record documentation.
Complaint Details
Complaints IN00391999, IN00389458, IN00389366, IN00388900, and IN00385445 were substantiated with state deficiencies cited at R297 and R349. Complaints IN00387654 and IN00388446 were unsubstantiated due to lack of evidence.
Findings
The facility failed to provide pharmacy services ensuring continued availability of medications for 7 of 8 residents reviewed, and failed to document all prescribed drugs or reasons for missed doses for 8 of 8 residents reviewed. Multiple medications were not administered as ordered, often due to unavailability, and documentation was incomplete or missing in progress notes.
Deficiencies (2)
Failed to provide pharmacy services for continued availability of medications for 7 of 8 residents reviewed.
Failed to document all prescribed drugs or reasons doses were not given for 8 of 8 residents reviewed.
Report Facts
Residents reviewed for medication administration: 8
Residents reviewed for prescribed medications documentation: 8
Survey dates: November 15, 16, 18, 2022
Deficiency completion date: January 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Piper Bakrevski | Senior Clinical Advisor | Signed the report and involved in quality review. |
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