B+
82/100Windemere Park Health and Rehabilitation Center Inspection Report, Violations & Safety Grade (Warren, Michigan)
31800 Van Dyke Avenue, Warren, Michigan 48093
Phone: 5867222600
CMS Overall:4/5
Overview & Bed Count
Certified Beds
92
Avg Residents/Day
55
Ownership
For profit - Individual
Provider Type
Medicare and Medicaid
County
Macomb
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health4/5
Staffing3/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Michigan Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.55 | 0.78 | -0.23 |
| Total Nurse Hours per Resident per Day | 4.13 | 4.03 | +0.11 |
| CMS Staffing Rating | 3/5 | 3.6/5 | - |
| Nursing Staff Turnover | 60.3% | 44.6% | - |
Health Citation History
25 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-06-11 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2026-04-07 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2026-02-18 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2025-04-30 | Nutrition and Dietary Deficiencies | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | F – Moderate Harm Potential |
| 2025-04-30 | Nutrition and Dietary Deficiencies | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | D – Moderate Harm Potential |
| 2025-04-30 | Environmental Deficiencies | Make sure that a working call system is available in each resident's bathroom and bathing area. | D – Moderate Harm Potential |
| 2024-10-01 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from the wrongful use of the resident's belongings or money. | D – Moderate Harm Potential |
| 2024-10-01 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-07-16 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-04-04 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-04-04 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2024-04-04 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E – Moderate Harm Potential |
| 2024-04-04 | Environmental Deficiencies | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | E – Moderate Harm Potential |
| 2024-04-04 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D – Moderate Harm Potential |
| 2023-01-11 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | F – Moderate Harm Potential |
| 2023-01-11 | Nutrition and Dietary Deficiencies | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | F – Moderate Harm Potential |
| 2023-01-11 | Administration Deficiencies | Have a plan that describes the process for conducting QAPI and QAA activities. | F – Moderate Harm Potential |
| 2023-01-11 | Administration Deficiencies | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F – Moderate Harm Potential |
| 2023-01-11 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2023-01-11 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2023-01-11 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | D – Moderate Harm Potential |
| 2023-01-11 | Resident Rights Deficiencies | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. | D – Moderate Harm Potential |
| 2023-01-11 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2023-01-11 | Pharmacy Service Deficiencies | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D – Moderate Harm Potential |
| 2023-01-11 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
Fire Safety Citation History
28 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-04-30 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2025-04-30 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2025-04-30 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | F – Moderate Harm Potential |
| 2025-04-30 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-04-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-04-30 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2025-04-30 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2025-04-30 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2025-04-30 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | E – Moderate Harm Potential |
| 2024-04-04 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-04-04 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2024-04-04 | Services Deficiencies | Have elevators that firefighters can control in the event of a fire. | F – Moderate Harm Potential |
| 2024-04-04 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-04-04 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2024-04-04 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2023-01-11 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2023-01-11 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2023-01-11 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | F – Moderate Harm Potential |
| 2023-01-11 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2023-01-11 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2023-01-11 | Construction Deficiencies | Meet other general requirements. | E – Moderate Harm Potential |
| 2023-01-11 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2023-01-11 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2023-01-11 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2023-01-11 | Miscellaneous Deficiencies | Have restrictions on the use of portable space heaters. | E – Moderate Harm Potential |
| 2023-01-11 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | D – Moderate Harm Potential |
| 2023-01-11 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | D – Moderate Harm Potential |
| 2023-01-11 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
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3-Year Complete Report ($19)
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Warren area at no cost.
Find Safe, Vetted Facilities Near Warren
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.