Inspection Reports for
Windemere Park Assisted Living I
31900 Van Dyke Avenue, Warren, MI, 48093
Back to Facility Profile11 Reports
Inspection Report — Jun 9, 2026
Complaint Investigation
Date: Jun 9, 2026
Visit Reason
Investigation of a complaint received on 2026-06-04 about resident care and staffing.
Complaint Details
Resident A sent to hospital with soiled clothing: established. Resident B had head lice: not established. One staff member on shift for each floor: established. Bed sheets not changed or cleaned: not established. Facility has roaches: not established. Residents' rooms not cleaned: not established. Additional findings: failure to maintain resident files and service plans — established.
Findings
Four violations were established related to resident care, staffing levels, and record keeping; three of these are repeat violations.
Deficiencies (4)
R 325.1931 Employees; general provisions: the facility did not have records showing Resident A getting showers or refusals, and the administrator did not maintain a service plan for Residents A and B, substantiating neglect of personal care and dignity.
R 325.1931 Employees; general provisions: the facility did not have adequate and sufficient staff on duty at all times, with only one staff member covering both the first and third floors during the midnight shift.
R 325.1921 Governing bodies, administrators, and supervisors: the administrator did not maintain files on residents, relying on PACE for records, constituting a repeat violation.
R 325.1922 Admission and retention of residents: the facility did not maintain or update resident service plans for Residents A, B, and C, constituting a repeat violation.
Report Facts
Corrective action plan due: 15
Inspection Report — Dec 11, 2025
Complaint Investigation
Date: Dec 11, 2025
Visit Reason
Investigation of a complaint received on 2025-12-10 about inadequate care and medication administration.
Complaint Details
Inadequate care for Resident A: established. Resident A was not administered her breathing treatments: established. Additional findings: not established.
Findings
Two violations were established related to inadequate care and failure to administer prescribed breathing treatments to Resident A.
Deficiencies (2)
R 325.1931 Employees; general provisions: staff did not respond to Resident A's call light in a timely manner, failing to attend to her personal needs consistent with her service plan.
R 325.1932 Resident medications: Resident A was not administered her prescribed breathing treatments as ordered by the licensed health care professional.
Report Facts
Corrective action plan due: 15
Inspection Report — Jul 10, 2025
Complaint Investigation
Date: Jul 10, 2025
Visit Reason
Investigation of a complaint received on 2025-07-03 about neglect and unmet care needs.
Complaint Details
Resident A was left soaked in urine for hours with severe catheter injuries, unmet care needs, and a pressure ulcer — established. Call light not answered for over 90 minutes — established. Additional findings — established.
Findings
Three rule violations were established related to neglect of Resident A, failure to maintain resident files, and failure to update service plans annually.
Deficiencies (3)
R 325.1921 Employees; general provisions: the facility did not comply with maintaining an organized program to provide protection, supervision, and personal care as Resident A was left soaked in urine for hours with severe catheter injuries and call light response times were lengthy.
R 325.1921 Governing bodies, administrators, and supervisors: the administrator did not maintain a file on Resident A, a PACE recipient residing on the second floor.
R 325.1922 Admission and retention of residents: the facility did not update Resident A’s service plan annually; the last update was on 02/22/2022.
Report Facts
Corrective action plan due: 15
Inspection Report — Mar 5, 2025
Renewal
Date: Mar 5, 2025
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The facility was found to be in noncompliance with 3 rules; a written corrective action plan was required before the license is renewed.
Deficiencies (3)
R 325.1932 Resident’s medications: a review of the medication log showed that the narcotic was not always completed, and the count sheet was not always signed or initialed by the staff.
R 325.1970 Water supply systems: the toilet in Room 154 was clogged.
R 325.1979 General maintenance and storage: Residents’ Rooms 154, 336, 340 and 355 were not clean, with clothes spread throughout the floors and bad odors.
Report Facts
Corrective action plan due: 15
Inspection Report — Jul 18, 2024
Complaint Investigation
Date: Jul 18, 2024
Visit Reason
Investigation of a complaint received on 2024-07-15 about neglect, staffing, training, medication, meals, and maintenance.
Complaint Details
Residents neglected: established. Insufficient staff: established. Staff training inadequate: established. Medication errors: established. Meals not provided timely: established. Maintenance issues: established. Additional findings: cigarette lighter accessible — established; unlocked medication cart — established; unsanitary rooms — established.
Findings
7 rule violations were established including neglect of residents, insufficient staffing, inadequate staff training, medication errors, failure to provide meals, lack of maintenance, and unsafe conditions related to resident access to cigarettes and unlocked medication cart.
Deficiencies (9)
R 325.1931 Employees; general provisions: the home failed to treat residents with dignity and attend to their personal needs consistent with their service plans, as residents did not always receive care such as showers and assistance.
R 325.1931 Employees; general provisions: the home did not have adequate and sufficient staff on duty at all times to meet resident needs consistent with service plans, with discrepancies in staffing schedules and actual staff present.
R 325.1931 Employees; general provisions: the home failed to train agency staff provided by PACE, although they consistently provided care to residents.
R 325.1932 Resident medications: the home did not supervise medication administration in accordance with residents' service plans, with medication often arriving late and errors such as morphine given instead of anxiety medication.
R 325.1952 Meals and special diets: the home failed to ensure residents were brought down to the dining room for meals and sometimes residents did not receive meals timely.
R 325.1979 General maintenance and storage: the building, equipment, and furniture were not kept clean and in good repair, with broken tiles, wet ceiling tiles, broken air conditioning unit, and broken ice machine observed.
R 325.1921 Governing bodies, administrators, and supervisors: resident E had access to a cigarette lighter in the dining room, posing a safety risk to residents requiring continuous supervision.
R 325.1932 Resident medications: medication cart was found unlocked with no medication technician nearby, risking unauthorized access to medications.
R 325.1962 Exteriors: residents' rooms were not always clean and free from odors such as urine, indicating premises were not maintained in a safe and sanitary condition.
Report Facts
Corrective action plan due: 15
Inspection Report — May 30, 2024
Complaint Investigation
Date: May 30, 2024
Visit Reason
Investigation of a complaint received on 2024-05-23 about Resident A's care including showers, laundry, meals, and visitor program.
Complaint Details
Facility lacked an organized visitor program: not established. Resident A lacked showers: established. Resident A lacked laundry services: established. No lunch served on 5/11/2024 and meals late: not established. Additional findings: not established.
Findings
Two rule violations were established related to Resident A's personal care and laundry services. Other allegations including visitor program and meal service were not substantiated.
Deficiencies (2)
R 325.1933 Personal care of residents: Resident A did not receive showers in accordance with his twice weekly schedule, confirming a violation.
R 325.1935 Bedding, linens, and clothing: There was no documentation indicating Resident A's bedding and laundry had been done as scheduled, confirming a violation.
Report Facts
Corrective action plan due: 15
Inspection Report — May 3, 2024
Complaint Investigation
Date: May 3, 2024
Visit Reason
Investigation of a complaint received on 2024-05-02 about Resident A's care and blood sugar monitoring.
Complaint Details
Resident A blood sugar and abrasion concerns: not established. Additional findings: lack of service plan for Resident A — established.
Findings
One rule violation was established related to the lack of a completed service plan for Resident A. One allegation was not established.
Deficiencies (1)
R 325.1931 Governing bodies, administrators, and supervisors: Resident A did not have a completed service plan, and the facility did not comply with this rule.
Report Facts
Corrective action plan due: 15
Inspection Report — Apr 5, 2024
Renewal
Date: Apr 5, 2024
Visit Reason
Renewal inspection of the home for the aged license.
Findings
The facility is in compliance with all applicable rules and statutes.
Inspection Report — Dec 1, 2023
Complaint Investigation
Date: Dec 1, 2023
Visit Reason
Investigation of a complaint received on 2023-11-29 about Resident A's personal hygiene and medication management.
Complaint Details
Resident A’s personal hygiene needs are not being met: established. Additional findings regarding medication management: established.
Findings
Two violations were established related to personal care and medication management for Resident A.
Deficiencies (2)
R 325.1933 Personal care of residents: facility staff could not demonstrate that personal care tasks, including weekly bathing, were completed for Resident A.
R 325.1932 Resident medications: Resident A’s service plan does not identify prescribed medication to be self-administered or managed by the home and lacks instructions for staff on addressing medication refusals.
Report Facts
Corrective action plan due: 15
Inspection Report — Oct 13, 2023
Complaint Investigation
Date: Oct 13, 2023
Visit Reason
Investigation of a complaint received on 2023-10-12 about resident care and facility operations.
Complaint Details
The Resident of Concern did not receive appropriate assistance: established. The ROC did not receive appropriate assistance because the facility was short staffed: not established. The ROC was not provided her special diet: established. The ROC was not able to enter or exit the building when she needed to: established. Additional findings: failure to maintain proper records — established.
Findings
Four violations were established related to resident assistance, special diet provision, building access, and record keeping.
Deficiencies (4)
R 325.1921 Governing bodies, administrators, and supervisors: the resident missed at least one dialysis treatment which the facility was to coordinate transportation for.
R 325.1952 Meals and special diets: the facility did not provide a special renal diet to the resident as prescribed.
R 325.1921 Governing bodies, administrators, and supervisors: residents do not have a reliable way of getting into the facility after business hours.
MCL 333.20175 Maintaining record for each patient; wrongfully altering or destroying records; noncompliance: the facility did not document important observations regarding the resident.
Report Facts
Corrective action plan due: 15
Inspection Report — Oct 30, 2012
Original Licensing
Date: Oct 30, 2012
Visit Reason
Original license application for a home for the aged.
Findings
The study determined substantial compliance with applicable licensing statutes and administrative rules; no rule or statutory violations were found.
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