Windemere Park Assisted Living I operates 90 beds in Warren, Michigan (Macomb County) at 31900 Van Dyke Avenue. Services include independent living, assisted living, memory care, and skilled nursing. Owner: Van Dyke Partners LLC. Administrator: Lisa Cavaliere-Mancini.
The facility presents extensive physical plant amenities including indoor heated pool, full-size theatre, Tuscany Restaurant with licensed dietitian, fitness facilities, on-site home care, visiting physicians, and daily pharmacy delivery. Emergency call pendants available. Rehabilitation services and respite care offered. Walk Score of 38 indicates limited walkability with most errands requiring transportation.
Most recent inspections on July 10, 2025 documented two concurrent substantiated complaints. One complaint alleged a resident was left soaked in urine for hours with severe catheter injuries, unmet care needs, and pressure ulcers, with call lights unanswered for over 90 minutes.
A second complaint alleged a resident was found deceased on the floor next to her bed on July 3, 2025 after an apparent fall. The resident’s service plan required two-hour checks; PACE staff failed to perform required rounding. The administrator lacked documentation regarding the incident.
Three deficiencies resulted from the first complaint addressing failure to maintain organized care program and failure to update service plans. Two deficiencies resulted from the second addressing failure to provide care consistent with service plan and inadequate incident documentation.
The facility accumulated 29 deficiencies over 13 years (263 percent above Michigan average). Deficiency rate averages 2.1 per year (250 percent above state average). Substantiated complaints span resident neglect and unmet care needs (February 2024, July 2024), inadequate staffing and training (July 2024), medication administration errors (July 2024), failure to provide prescribed meals and specialized diets (February 2024, July 2024), incomplete personal hygiene care and documentation (December 2023), maintenance failures including broken air conditioning and broken plumbing (July 2024), unsafe conditions including accessible hazardous items (July 2024), and inadequate documentation and incident reporting (January 2023, December 2023).
Multiple complaint investigations were substantiated. The facility received only two clean inspections in 13 years of available records (March 2024 and March 2023). No civil monetary penalties, immediate jeopardy findings, or license suspension actions appear in the record despite documented resident harm. Occupancy declined sharply from 47 residents in July 2024 to 26 residents in July 2025, indicating only 29 percent current capacity.
The two resident complaints documented on July 10, 2025 represent acute safety failures. Catheter neglect resulting in severe injuries and the death of a resident following missed required care checks establish documented patterns of inadequate supervision and care plan noncompliance. The administrator’s lack of incident documentation regarding the resident death compounds the concern.
The facility’s occupancy collapse to 29 percent suggests that families aware of the record are declining enrollment or withdrawing current residents.
Families should request the July 2025 resident death incident report, staffing credentials, policies for service plan compliance, medication administration protocols, and corrections implemented.
