Inspection Reports for Wyndmoor of Portage, LLC
3444 SWANSON RD, PORTAGE, IN, 46368
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 5, 2025, identified deficiencies related to incomplete transfer/discharge paperwork, failure to update wound care service plans, and inaccurate clinical records. Earlier inspections showed a pattern of issues involving clinical documentation, service plan updates, and staff training, with some citations related to resident rights and safety concerns such as pest control and medication administration. Complaint investigations were mixed, with several substantiated complaints resulting in deficiencies, while others were found to have no deficiencies. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s inspection history shows ongoing challenges with documentation and care planning, with no clear trend of overall improvement or worsening.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
2% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
80 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 3
Date: May 5, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00455828 and IN00456693. Complaint IN00455828 resulted in state deficiencies related to the allegations, while Complaint IN00456693 had no deficiencies cited.
Complaint Details
Complaint IN00455828 was substantiated with state deficiencies cited at R0045, R0217, and R0349. Complaint IN00456693 had no deficiencies related to the allegations.
Findings
The facility failed to ensure transfer/discharge papers were completed and notifications to the resident's responsible party and physician were made for transfers. Additionally, service plans were not updated to reflect changes in wound care treatment orders, and clinical records were incomplete and inaccurate regarding wound care documentation.
Deficiencies (3)
Failed to ensure transfer/discharge papers were completed and the resident's responsible party and physician were notified when a resident was transferred out of the facility.
Failed to ensure service plans were updated with changes for wound care treatment.
Failed to maintain clinical records that were complete and accurate related to updating a treatment order for wound care.
Report Facts
Residential Census: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Williams | Executive Director | Named in relation to findings and interviews regarding transfer/discharge documentation and facility policies |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Date: Jan 9, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00445170.
Complaint Details
Complaint IN00445170 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Wyndmoor Of Portage was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00445170.
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 3
Date: Jun 19, 2024
Visit Reason
This visit was for the investigation of complaints IN00434795, IN00435357, IN00436019, IN00436226, and IN00436508.
Complaint Details
Investigation of complaints IN00434795, IN00435357, IN00436019, IN00436226, and IN00436508. Deficiencies were cited related to complaints IN00435357 and IN00436508. Complaints IN00434795, IN00436019, and IN00436226 had no deficiencies cited.
Findings
The facility was cited for deficiencies related to staff CPR certification for 6 of 16 shifts, failure to update a resident's service plan related to smoking, and incomplete medication administration documentation for one resident. Some complaints had no deficiencies cited.
Deficiencies (3)
Failed to ensure one staff member with current CPR certificate for 6 of 16 shifts reviewed.
Failed to update a Service Plan related to smoking for 1 of 3 residents reviewed.
Failed to ensure clinical records were complete and accurate related to medications not signed out as administered for 1 of 3 records reviewed.
Report Facts
Shifts without CPR certified staff: 6
Resident census: 85
Medication administration omissions: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Zella Garron | Executive Director | Signed the report and was interviewed regarding CPR certification compliance. |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 6
Date: Apr 22, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the Investigation of Complaint IN00430991.
Complaint Details
Complaint IN00430991 was investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. However, multiple deficiencies were found related to personnel training documentation, sanitation and safety standards regarding a resident's pet, medication administration errors, food preparation, pharmaceutical services, and clinical record documentation.
Deficiencies (6)
Failed to ensure required personnel documentation for references, job orientation, and annual inservices including Dementia, Abuse, and Resident Rights were completed for 4 of 5 staff members reviewed.
Failed to ensure a resident with a pet had an environment that was clean, sanitary, and free of odors.
Failed to ensure a blood pressure medication was held per Physician's Orders for 1 of 7 records reviewed.
Failed to ensure food was prepared in a form to meet individual needs related to incorrectly made pureed food affecting 2 residents.
Failed to ensure each resident's drug regimen was reviewed at least once every 60 days by the Consulting Pharmacist for 5 of 7 records reviewed.
Failed to ensure clinical records were complete and accurately documented related to lack of follow up documentation after a change in condition and no order to self administer medications for 1 of 7 records reviewed.
Report Facts
Residential Census: 84
Staff members reviewed: 5
Residents reviewed for medication errors: 7
Residents reviewed for pharmaceutical services: 7
Residents reviewed for clinical records: 7
Dates of survey: 2024-04-22 to 2024-04-23
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 3
Date: Feb 5, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427160 and IN00427196 concerning resident safety and facility management issues.
Complaint Details
Complaint IN00427160 cited a state deficiency related to failure to report an elopement. Complaint IN00427196 cited state deficiencies related to failure to report unusual occurrences and failure to update service plans after elopement.
Findings
The facility failed to notify the State Agency of an unusual occurrence related to a resident elopement, failed to maintain an effective pest control program due to cockroach sightings in a resident room, and failed to update a resident's service plan with interventions after an elopement incident.
Deficiencies (3)
Failed to notify the State Agency of an unusual occurrence related to a resident elopement for 1 of 3 residents reviewed.
Failed to ensure an effective pest management program was in place related to a cockroach observed in 1 of 3 resident rooms.
Failed to ensure a Service Plan was updated with interventions for a resident after an elopement for 1 of 3 residents reviewed.
Report Facts
Residential Census: 88
Audit frequency: 4
Audit frequency: 2
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding failure to report elopement and responsible for auditing unusual occurrence logs and service plans. | |
| Wellness Director | Interviewed regarding updating service plans and elopement interventions. | |
| Housekeeper 1 | Reported cockroach sightings to management. | |
| Maintenance Director | Provided information about pest control visits and documentation. | |
| Regional Director of Operations | Re-educated Executive Director on unusual occurrences and state reportable events. |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415094.
Complaint Details
Complaint IN00415094 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00415094 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Report Facts
Residential Census: 90
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 2
Date: Mar 15, 2023
Visit Reason
This visit was for the investigation of Complaint IN00398774 related to allegations concerning residents' rights and Resident Council practices.
Complaint Details
Complaint IN00398774 was substantiated with state deficiencies cited at R0028 and R0040 related to residents' rights violations and Resident Council inclusivity issues.
Findings
The facility failed to ensure residents could exercise their rights without coercion or fear of retaliation, specifically related to requiring Resident Council Board members to sign a non-disclosure agreement (NDA). Additionally, the Resident Council was not inclusive, as the Board met privately and voted a resident off the Board, potentially affecting all residents wishing to participate.
Deficiencies (2)
Residents' rights were compromised by requiring Resident Council Board members to sign a non-disclosure agreement, creating potential coercion or fear of retaliation.
Resident Council was not inclusive; the Board met privately and excluded a resident by voting them off, limiting participation of all residents.
Report Facts
Residential Census: 92
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cornelius van der Velde | Executive Director | Named as the Administrator involved in the Resident Council Board meeting and corrective actions |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 0
Date: Aug 3, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00378450.
Complaint Details
Complaint IN00378450 was substantiated; however, no deficiencies related to the allegations were cited.
Findings
The complaint 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.
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