Silver Birch of Evansville – An Assisted Living Community at 475 S. Governor St. DENNY SIMMONS / COURIER & PRESS
Silver Birch of Evansville – An Assisted Living Community at 475 S. Governor St. DENNY SIMMONS / COURIER & PRESS
EVANSVILLE — On the morning of Aug. 30, 2019, a staff member at the assisted living facility Silver Birch of Evansville noticed a resident had failed to take her 7 a.m. medications.

The woman also typically ate breakfast in the facility’s dining room, but she was missing that morning.

According to an Indiana State Department of Health investigation, the concerned staff member went to the missing woman’s room at 11 a.m. to administer her morning medications.

There, he found the woman laying motionless in her bed, covered in her own vomit.

She had been dead for at least 16 hours, according to Indiana State Department of Health officials.

Documents reviewed by the Courier & Press show the state has cited Silver Birch of Evansville and other state-licensed assisted living facilities in Southern Indiana dozens of times since 2019 for failing to comply with regulations, including laws that protect residents from abuse and neglect.

Silver Birch of Evansville did not respond to the Courier & Press prior to publication.

Indiana State Department of Health surveyors cited facilities across Southern Indiana for a wide array of violations, including failures to thoroughly investigate allegations of sexual assault.

Michelle Motta, who advocates for nursing home residents as one Vanderburgh County’s long-term care ombudsman, said all facilities should immediately and thoroughly investigate any allegation of abuse or neglect. She urged residents’ family members to become familiar with signs of abuse.

“If anyone suspects a family member is abused by anyone, report it to administration and to the state immediately,” Motta said. “If retaliation is a concern, there (are) other ways to navigate the process.”

Facilities also received violations for mismanaging drugs, failing to keep kitchens clean and not protecting residents from COVID-19.

In one case from 2021, administrators at Oasis Assisted Living in Evansville fired the director of nursing after it was suspected she’d stolen dozens of opioid painkillers from a resident. The facility received at least 16 citations between 2019 and 2021.

A representative for Oasis declined to comment specifically on the alleged incident but did say the facility works hard to ensure any staff who violate protocol are disciplined.

Riverwalk Communities, an assisted living facility in Downtown Evansville, was cited six times by the state between 2020 and 2021 for failing to implement adequate COVID-19 control measures.

In a statement, Riverwalk Communities said staff cannot force residents to comply with the facility’s COVID-19 protocols. It also said it implemented state-approved corrective measures in response to the state’s findings.

Advocates described oversight of assisted living facilities as a statewide problem. The industry’s regulatory framework is “broken,” they said, and assisted living facilities often face little punishment — even for serious regulatory violations.

Silver Birch of Evansville cited 35 times in three years

Silver Birch of Evansville is a 100,000-square-foot complex with 119 apartment-style units located at 475 S. Governor St. The high-ceilinged lobby could be mistaken for a modern hotel, and the apartment units come complete with fauxwood floors and granite countertops.

Chicago-based Vermillion Development received approval to build the facility in 2017.

Vermillion Development subsidiary Silver Birch Living LLC operates nine assisted living facilities in Indiana. Vermillion’s website claims it is the largest developer of assisted living communities in the state.

According to the National Institute on Aging, assisted living facilities serve people who require daily help but who don’t need the level of services nursing homes provide.

State regulations prescribe a list of “residents’ rights” that facilities must uphold — guidelines that cover every aspect of resident care.

Problems at Silver Birch of Evansville trace back to its first year of operation, according to state records.

In November 2019, an investigation determined the facility “failed to thoroughly investigate an incident of sexual abuse” after a resident told staff she’d been sexually assaulted by another resident.

Administrators did not promptly notify the Evansville Police Department about the alleged assault, investigators said. A staff member allegedly described the accused resident as “a good guy who did a lot around the community.”

The same investigation found that an administrator told the victim “if she was lying, she would have to move out of the facility.”

In response to the state’s findings, company representatives outlined how staff members worked to protect the victim after she reported the assault and noted corrective action that managers would implement.

“An internal investigation began immediately, which included interviewing staff members and residents of the facility to determine if any other residents had been affected,” a portion of the written response said.

In March 2021, state investigators substantiated more than a dozen complaints against Silver Birch and determined 17 residents did not receive their prescribed morning and afternoon insulin doses in January 2021.

The state said the missed doses resulted from a failure to maintain sufficient numbers of qualified staff. In response, Silver Birch said it would increase monitoring of staffing levels. But it would soon be cited for staffing deficiencies again. The same report said the facility failed “to ensure safe food-handling techniques” and didn’t “properly prevent and/or contain COVID-19.”

In July 2021, state surveyors wrote that a Silver Birch resident was “handled roughly, grabbed roughly by staff and is afraid to sleep in her bed due to treatment by staff.”

The woman told surveyors she “had a little trauma thing.”

“A couple of staff had put five diapers on her, then they couldn’t get the pads under her and jerked it out,” the state report says. “She still won’t sleep in the bed and only sleeps in the chair now due to [being] ‘traumatized.’ ... They had taken her call light, and she was afraid no one would come, and it scared her.”

Silver Birch investigated the incident and reported it to the state, according to public records. Silver Birch’s report found that two staff members were “rough and inconsiderate with resident.”

The two employees were fired, the report states.

Ten other facilities cited dozens of times

According to Indiana statute, state surveyors’ findings are used as evidence when determining if a facility breached regulations and deserves an official citation.

State records detail 170 potential regulation breaches at state-licensed assisted living facilities in Southern Indiana.

At Primrose of Newburgh, two staff members were “written up” over allegations they’d verbally abused residents, according to a state complaint investigation from January 2021. The documents say both staff members quit once they were reprimanded.

The report discusses a Primrose of Newburgh resident who suffered from blindness and dementia who called a family member late one night in fear, saying a staff member told her, “I’ll fight you.”

Alleged incidents of verbal abuse were documented in state reports at multiple facilities in the Evansville area.

In June 2020, the state cited Riverwalk Communities for failing to administer multiple doses of medication to a resident. The facility, along with several others, was also cited for not dispensing as-needed medications properly.

Others across Southern Indiana were cited at least 20 times for breaching regulations designed to mitigate the spread of COVID-19. The pandemic wreaked havoc at assisted living facilities and nursing homes throughout Indiana.

State health department reports also documented violence between residents and staff members at different facilities.

Video footage cited in a state investigation from 2019 detailed an incident between a resident and staff member at Oasis Assisted Living, located at 4301 Washington Ave. in Evansville.

According to state documents, a resident hit a staff member, who in turn slapped the resident and pushed her into a wall. The state cited the facility for failing to thoroughly investigate a potential case of abuse.

The Courier & Press left messages seeking comment from officials at Primrose of Newburgh, Riverwalk Communities, Legacy Living of Jasper and Oasis Assisted Living.

Financial penalties top out at $10,000

Many Indiana assisted living facilities are regulated at the state level. If a facility violates regulations, the health department can respond with sanctions depending on the severity of the breach.

“Offenses” – the most serious violations – present a substantial probability that death or a life-threatening condition will result, according to state regulations.

The maximum allowable fine for an offense is $10,000, but if the violation is “immediately corrected,” the penalty can be reduced by up to half.

“Deficiencies” pose an immediate or direct adverse effect on the health, safety, security, rights or welfare of residents. The maximum fine is $5,000, but that also be cut in half if the facility makes an immediate correction.

Since Silver Birch of Evansville opened in 2019, the state has cited the facility for at least five offenses and 18 deficiencies, according to documents.

The state also cited the facility for “noncompliance” at least nine times for failing to properly administer medications, not conducting regular fire drills and failing to implement adequate infection control measures.

In multiple cases, the facility received repeated citations for the same violations, such as failing to maintain an adequate number of staff or failing to properly dispense medication.

Few Southern Indiana facilities received large financial penalties for violations, according to state records.

But even those numbers don’t tell the full story. A single offense or deficiency can be connected to an incident that impacted multiple residents.

Likewise, a single event can result in multiple deficiencies if the state determines an action violated more than one regulation.

Problems are systemic


Advocates say financial penalties in the thousands of dollars do little to curb repeated violations by assisted living facilities, large corporations and hospitals.

State and local long-term care ombudsman help facility residents and their families resolve complaints and solve problems. They also answer questions and provide advice, for free, to anyone who requests it.

Motta and Alicia Reeves serve in those roles for Vanderburgh County. They said the industry suffers from systemic regulatory problems that make it difficult to hold facilities accountable.

“It’s just kind of a cycle,” Reeves said when asked about how complaints are investigated. “It’s even very rare that we see that (a facility) gets fined.”

Motta and Reeves said the pandemic made it more difficult to resolve residents’ complaints, and the overall quality of care deteriorated as residents lost access to supplemental care from family members.

At the height of the pandemic, the Indiana State Department of Health stopped in-person complaint investigations. Instead, the state performed COVID- 19 infection control surveys, which found widespread failures to enforce basic safety measures.

“We’ve talked to a surveyor who had to remind the administrator to put their mask on as they were speaking face-to-face,” Reeves said.

According to state data, COVID-19 had killed 6,052 long-term care facility residents in Indiana by March 14, 2022.

When complaint investigations resumed, Reeves said facilities received a high number of citations but faced little serious punishment. In state investigations, one of the most commonly cited problems is a failure to properly manage and dispense residents’ medications, documents show.

“I do hear a lot of complaints about the assisted living (facilities) that have to do with medication, where they ran out of the medication, residents didn’t get it in a timely manner, or they didn’t get the right medication,” Motta said.

Both Motta and Reeves said regulatory reforms announced by President Joe Biden’s administration in March 2021 promise to bring about positive change to the long-term care industry.

The reforms would withdraw tax dollars from poorly performing nursing homes and bolster the number of qualified staff at facilities. Motta said a mandated staff-to-resident ratio would improve outcomes for residents, staff and the industry as a whole.

“There needs to be more staff so that things can get done, and they can take their time feeding Mary so Mary’s not losing weight; so they can take the time to put lotion on George’s legs,” Motta said. “That’s the hope with there being a staff-to-resident ratio … is that the hands-on staff are caring for that person, they’re providing care in a caring way.”

Advocates across the U.S. are pushing for reforms at the state level, too. Mandated staffing levels are a top priority, as is an overhaul to the system that publicly discloses cases of abuse, neglect and other regulatory breaches at facilities.

Both Motta and Reeves said many residents and family members never see the state documents detailing complaint investigations or facility citations. Accessing state records is cumbersome and time consuming, they said, and facilities’ marketing materials do little to hint at what can go wrong inside a long-term care facility.

Motta urges anyone with questions or concerns about a loved one’s care inside a nursing home or assisted living facility to call their local ombudsman. Contact information can be found at the state’s ombudsman website or by calling 317-232-7134.

Long-term care residents and their family members in Vanderburgh County can call 812-423-2927 for assistance.

The services are free, and Motta said ombudsmen across the state are there to help residents and family members solve problems.

“We’re happy to talk to people and just let them tell us what’s going on, and we’ll see what we can do to help, or give them some information that they may be able to use to advocate for their loved one,” Motta said. “Because information is power.”
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