Inspection Reports for Wyndmoor of Marion, LLC
2452 W KEM RD, MARION, IN, 46952
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 7, 2025, found the facility in compliance with no deficiencies cited during the follow-up to a prior complaint investigation. Earlier inspections showed a pattern of some deficiencies related mainly to resident care and staff certification, including issues with ensuring assistive devices were provided, expired staff certifications, and improper resident discharges without adequate documentation. Complaint investigations were often unsubstantiated, though some were substantiated with findings such as failure to prevent resident injury, inadequate discharge procedures, and delayed abuse reporting; no fines or enforcement actions were listed in the available reports. The facility addressed identified issues through corrective actions like staff training and monitoring certifications. The inspection history suggests improvement over time, with recent visits showing compliance after earlier citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
77 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 77
Deficiencies: 0
Date: Apr 7, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00451646 completed on February 4, 2025.
Complaint Details
Complaint IN00451646 was corrected.
Findings
Wyndmoor of Marion was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00451646.
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00453069.
Complaint Details
Complaint IN00453069 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 1
Date: Feb 3, 2025
Visit Reason
This visit was for the investigation of complaints IN00451292, IN00451382, and IN00451646. Complaints IN00451292 and IN00451382 had no deficiencies related to the allegations cited. Complaint IN00451646 resulted in state deficiencies related to the allegations.
Complaint Details
Complaint IN00451646 was substantiated with state deficiencies cited. Complaints IN00451292 and IN00451382 had no deficiencies related to the allegations.
Findings
The facility failed to ensure a rollator walker was provided according to the service plan for a resident at risk for falls, resulting in a fall that caused two fractures and a ruptured tendon requiring surgical repair. The facility implemented corrective actions including staff in-service and auditing of residents' use of assistive devices during outings.
Deficiencies (1)
Failed to ensure a rollator walker was provided in accordance with the service plan to meet the needs of a resident at risk for falls, resulting in injury.
Report Facts
Residential Census: 77
Survey Dates: Inspection conducted on February 3 and 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra L. Dixon | Executive Director | Signed the report |
| Activity Assistant 4 | Interviewed regarding resident's walker use during outings | |
| Activity Director | Interviewed regarding resident's fall and walker use | |
| DON | Director of Nursing | Interviewed regarding CNA care sheets and resident interventions |
| Assistant Director of Nursing | Provided facility policy on outings |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Date: Oct 11, 2024
Visit Reason
This visit was for a State Residential Licensure Survey, which included the Investigation of Complaint IN00443931.
Complaint Details
Complaint IN00443931 was investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the complaint allegations were cited. However, deficiencies were found related to expired certifications for direct care staff and Qualified Medication Aides (QMA), with corrective actions implemented to remove unlicensed staff from schedules and monitor license expirations.
Deficiencies (2)
Failed to ensure direct care staff had current certification for 2 of 30 employees reviewed; CNA 4 and CNA 5 had expired certifications but worked shifts after expiration.
Failed to ensure Qualified Medication Aides had current certifications for 2 of 30 employees reviewed; QMA 2 and QMA 3 had expired certifications but worked shifts after expiration.
Report Facts
Employees reviewed for certification: 30
Residents present: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Dixon | executive director | Signed the report. |
| Director of Nursing | Director of Nursing | Provided staff daily shift roster and was interviewed regarding expired certifications. |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 1
Date: Sep 16, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00441864 regarding allegations of improper involuntary discharges at the facility.
Complaint Details
Complaint IN00441864 was substantiated with state deficiencies cited related to allegations of improper involuntary discharges for Residents B, C, and J. The facility did not provide adequate documentation or notification to the Area Ombudsman regarding the 30-day discharge notices.
Findings
The facility failed to protect residents' rights to be free from discharge without indication for 3 residents (B, C, and J). Documentation supporting the reasons for involuntary discharges was lacking, and notifications to the Area Ombudsman were not received. Issues included medication security, substance use, smoking policy violations, and failure to accommodate residents' needs related to smoking.
Deficiencies (1)
Facility failed to protect residents' rights to be free from discharge without indication for 3 residents (B, C, and J).
Report Facts
Residential Census: 77
30-day notice effective date: 2024
Resident J owed amount: 11000
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Date: Jul 10, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00435076, IN00436740, and IN00437021.
Complaint Details
Complaints IN00435076, IN00436740, and IN00437021 were investigated and no deficiencies related to the allegations were found.
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 the investigation of these complaints.
Report Facts
Residential Census: 78
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Date: Apr 22, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00431961 and IN00432847.
Complaint Details
Complaint IN00431961 and Complaint IN00432847 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00431961 and IN00432847 were cited. The facility was found to be in compliance with applicable regulations.
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 0
Date: Feb 12, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00428015, IN00428038, and IN00428041.
Complaint Details
Investigation of Complaints IN00428015, IN00428038, and IN00428041 found no deficiencies related to the allegations; facility was in compliance.
Findings
No deficiencies related to the allegations in complaints IN00428015, IN00428038, and IN00428041 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 0
Date: Dec 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00421069.
Complaint Details
Complaint IN00421069 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00421069 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: 77
Deficiencies: 0
Date: Oct 19, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418937.
Complaint Details
Complaint IN00418937 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: 80
Deficiencies: 1
Date: Aug 30, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on August 29 and 30, 2023.
Findings
The facility failed to ensure food was cooked adequately to destroy pathogens when unpasteurized eggs were used in the preparation of soft-cooked eggs for 17 of 80 residents. The Dietary Manager used raw unpasteurized shell eggs for various egg preparations despite the risk of foodborne pathogens such as Salmonella.
Deficiencies (1)
Facility failed to ensure food was cooked adequately to destroy pathogens when unpasteurized eggs were utilized in the preparation of soft-cooked eggs for 17 of 80 residents.
Report Facts
Residents affected: 17
Residential Census: 80
Eggs of choice served: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cassandra Dixon | Executive Director | Signed the report |
| Dietary Manager | Used unpasteurized eggs and was interviewed regarding egg preparation practices | |
| Administrator | Interviewed regarding policies and egg usage | |
| Dietary Cook 3 | Interviewed about resident egg preferences and knowledge of food safety |
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Date: May 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409084.
Complaint Details
Complaint IN00409084 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: 76
Deficiencies: 0
Date: Apr 19, 2023
Visit Reason
This visit was for the investigation of complaints IN00404927 and IN00406519.
Complaint Details
Investigation of Complaints IN00404927 and IN00406519 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00404927 and IN00406519 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 2
Date: Feb 13, 2023
Visit Reason
This visit was for the investigation of Complaint IN00401336, which was substantiated with related findings cited.
Complaint Details
Complaint IN00401336 was substantiated. The investigation found issues related to residents' discharge preparation and service plan development.
Findings
The facility failed to ensure residents were prepared for and appropriately discharged, specifically for two residents who were involved in drug use and safety incidents. Additionally, the facility failed to develop a service plan for one resident as required.
Deficiencies (2)
Failure to ensure residents were prepared for and appropriately discharged, including immediate discharge due to drug use and safety concerns for two residents.
Failure to develop a service plan for one resident upon admission.
Report Facts
Residential Census: 81
Drug screen positive results: 3
Audit frequency: 4
Audit frequency: 2
Service plan review frequency: 6
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 4
Date: Dec 12, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00396493. The complaint was substantiated with state residential findings related to abuse and administration cited.
Complaint Details
Complaint IN00396493 was substantiated. The complaint involved Resident B who was verbally abused by LPN 6 when she refused to assist the resident back into bed and made rude comments. The facility delayed reporting the abuse to the State Agency until 12/7/22. The investigation was incomplete and did not include interviews with other residents. Additional incidents involving Resident D exhibiting aggressive and bullying behavior were noted but not reported to the Administrator.
Findings
The facility failed to prevent abuse for one resident and failed to report allegations of abuse timely to the State Agency. Staff did not provide assistance to a resident needing help getting back into bed and were verbally abusive. The facility also failed to ensure staff reported potential abuse per policy and failed to provide required training on residents' rights, dementia, and abuse for one employee.
Deficiencies (4)
Failed to prevent verbal abuse for 1 of 5 residents reviewed (Resident B).
Failed to complete a thorough investigation and report allegations of abuse to the State Agency for 1 of 1 allegations reviewed.
Failed to ensure staff reported potential abuse to the Administrator per facility policy for 3 of 3 potential incidents reviewed.
Failed to provide training on residents' rights, dementia, and abuse for 1 of 7 employee files reviewed (CNA 21).
Report Facts
Residential Census: 83
Date of survey: Dec 12, 2022
Date of survey: Dec 13, 2022
Employee hire date: Sep 13, 2022
Plan of Correction Completion Date: Jun 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 6 | Licensed Practical Nurse | Named in verbal abuse incident toward Resident B and subsequent termination |
| CNA 21 | Certified Nursing Assistant | Employee file reviewed; lacked required training on residents' rights, dementia, and abuse |
| Administrator | Involved in handling abuse complaint and investigation | |
| DON | Director of Nursing | Provided investigation details and interviews |
| Camille Beeson | AIT Preceptor | Responsible for auditing incident reports and staff training |
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Date: Nov 21, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00390320.
Complaint Details
Complaint IN00390320 - Substantiated. No deficiencies related to the allegations are cited.
Findings
Complaint IN00390320 was substantiated, but 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: 85
Deficiencies: 1
Date: Aug 29, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388486. The complaint was substantiated, but no state residential findings related to the allegations were cited; unrelated deficiencies were noted.
Complaint Details
Complaint IN00388486 was substantiated. No state residential findings related to the allegations were cited. The complaint involved a resident falling from his powerchair on a facility bus due to lack of proper securing.
Findings
The facility failed to ensure that a resident's powerchair and the resident were safely secured while being transported in a facility bus, resulting in a resident falling out of his powerchair during transport. The incident caused minor injuries to the resident and another resident who was bumped. The facility lacked proper notification to the physician and had not updated the resident's service care plan following the incident.
Deficiencies (1)
The facility failed to ensure the resident's powerchair and the resident was safely secured while being transported in a facility bus.
Report Facts
Residential Census: 85
Date of incident: Aug 25, 2022
Date survey completed: Aug 30, 2022
Plan of correction completion date: Oct 1, 2022
Inspection Report
Renewal
Census: 81
Deficiencies: 0
Date: Aug 19, 2022
Visit Reason
This visit was for a State Residential Licensure Survey conducted on August 18-19, 2022.
Findings
Wyndmoor of Marion, LLC was found to be in compliance with 410 IAC 16.2-5 in regard to the State Residential Licensure Survey.
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