Cycle 1
Health 2025-04-30 · Fire 2025-04-30
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Warren, MI
Windemere Park Health and Rehabilitation Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
31800 Van Dyke Avenue, Warren, MI
(586) 722-2600
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2015-12-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.40
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.98
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
73%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
74%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,184
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9860
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.89
Baseline 21.31% · Performance 19.63% · Measure score 3.89 · Achievement 3.89 · Improvement 3.43
Healthcare-associated infections
2.34
Baseline 7.41% · Performance 7.13% · Measure score 2.34 · Achievement 2.34 · Improvement 0.63
Total nurse turnover
0.98
Baseline 76.92% · Performance 69.23% · Measure score 0.98 · Achievement 0 · Improvement 0.98
Adjusted total nurse staffing
4.98
Baseline 4.69 hours · Performance 4.50 hours · Measure score 4.98 · Achievement 4.98 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 63 · Observed rate 11.11% · Lower 95% interval 6.87% |
| Discharge to community | 50.7% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 39.71% · Lower 95% interval 38.83% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 23.33% |
95.27%
71.9 pts worse
|
Numerator 7 · Denominator 30 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 30 |
| Discharge self-care score | 77.27% |
53.69%
23.6 pts better
|
Numerator 17 · Denominator 22 |
| Discharge mobility score | 68.18% |
50.94%
17.2 pts better
|
Numerator 15 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 30 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.13% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 28 · Observed rate 7.14% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 5.68% |
8.2%
2.5 pts worse
|
Numerator 5 · Denominator 88 |
| Staff flu vaccination coverage | 13.24% |
42%
28.8 pts worse
|
Numerator 18 · Denominator 136 |
| Discharge function score | 68.18% |
56.45%
11.7 pts better
|
Numerator 15 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.9% |
95.0%
4.1 pts worse
|
93.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 90.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 76.7% |
95.0%
18.3 pts worse
|
95.5%
18.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 76.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.1%
1.7 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.3% · Q3 5.3% · Q4 0.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.1% |
4.1%
4 pts worse
|
11.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 18.9% · Q3 10.8% · Q4 2.5% · 4Q avg 8.1% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
5.5%
2.7 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 6.1% · Q4 2.7% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.2% |
19.6%
2.6 pts worse
|
19.6%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 18.9% · Q3 27.3% · Q4 27.0% · 4Q avg 22.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.2% |
16.5%
8.7 pts worse
|
16.7%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 31.2% · Q3 23.3% · Q4 20.0% · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 40.9% |
13.9%
27 pts worse
|
16.3%
24.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 40.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.4% |
11.7%
17.7 pts worse
|
14.9%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 44.1% · Q3 18.8% · Q4 22.9% · 4Q avg 29.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.3% |
0.9%
2.4 pts worse
|
1.0%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.8% · Q3 2.3% · Q4 5.1% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.4% |
20.4%
12 pts worse
|
19.8%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 21.3% · Q3 38.4% · Q4 38.7% · 4Q avg 32.4% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
5.6%
3.2 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.7% · Q3 1.8% · Q4 2.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.2% |
82.8%
4.6 pts worse
|
81.7%
3.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 38.0% · Q2 73.5% · Q3 98.7% · Q4 98.7% · 4Q avg 78.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.6% |
11.5%
8.9 pts better
|
12.0%
9.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.6% · Observed 2.7% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.3%
1.8 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.4% · Q4 4.8% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.4% |
79.5%
10.1 pts worse
|
79.7%
10.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.6% |
24.2%
2.4 pts worse
|
23.9%
2.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.6% · Observed 27.0% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2023-01-11 · Fire 2023-01-11
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
13 fire-safety deficiencies
Top issue: Miscellaneous (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-05-28
F · Potential for more than minimal harm
2025-04-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-28
F · Potential for more than minimal harm
2025-04-30
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-05-28
F · Potential for more than minimal harm
2025-04-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-28
F · Potential for more than minimal harm
2025-04-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-28
E · Potential for more than minimal harm
2025-04-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-28
E · Potential for more than minimal harm
2025-04-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-28
E · Potential for more than minimal harm
2025-04-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-28
E · Potential for more than minimal harm
2025-04-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-28
F · Potential for more than minimal harm
2024-04-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-15
F · Potential for more than minimal harm
2024-04-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-15
F · Potential for more than minimal harm
2024-04-04
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-05-15
F · Potential for more than minimal harm
2024-04-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-15
F · Potential for more than minimal harm
2024-04-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-15
F · Potential for more than minimal harm
2024-04-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-15
F · Potential for more than minimal harm
2023-01-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-02-20
F · Potential for more than minimal harm
2023-01-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-02-20
F · Potential for more than minimal harm
2023-01-11
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-02-20
F · Potential for more than minimal harm
2023-01-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-20
F · Potential for more than minimal harm
2023-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-20
E · Potential for more than minimal harm
2023-01-11
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-02-20
E · Potential for more than minimal harm
2023-01-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-20
E · Potential for more than minimal harm
2023-01-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-20
E · Potential for more than minimal harm
2023-01-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-02-20
E · Potential for more than minimal harm
2023-01-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-20
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-30
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-30
F808 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-30
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-05-28
D · Potential for more than minimal harm
2024-10-01
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-10-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-07-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-08
F · Potential for more than minimal harm
2024-04-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-15
F · Potential for more than minimal harm
2024-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-04
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-05-15
E · Potential for more than minimal harm
2024-04-04
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-05-15
D · Potential for more than minimal harm
2024-04-04
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-05-15
F · Potential for more than minimal harm
2023-01-11
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-02-20
F · Potential for more than minimal harm
2023-01-11
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-02-20
F · Potential for more than minimal harm
2023-01-11
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-02-20
F · Potential for more than minimal harm
2023-01-11
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-02-20
F · Potential for more than minimal harm
2023-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-20
E · Potential for more than minimal harm
2023-01-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-11
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-11
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-02-20
D · Potential for more than minimal harm
2023-01-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-02-20
Penalties and ownership
What sits behind the stars
Ownership
Windemere Group LLC
5% Or Greater Direct Ownership Interest · Organization
Hautamaki, David
W-2 Managing Employee · Individual
Johnson, Barbara
W-2 Managing Employee · Individual
Lisa Mancini Living Trust
5% Or Greater Indirect Ownership Interest · Organization
Mancini, Lisa
5% Or Greater Indirect Ownership Interest · Individual
Shenoy, Vijay
Corporate Director · Individual
Shenoy, Vijay
W-2 Managing Employee · Individual
Ventimiglia, Domenica
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Autumn Woods Residential Health
Warren, MI
2-star overall rating with 2-star inspections with abuse icon flag with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
St. Anthony Healthcare Center
Warren, MI
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
The Orchards at Warren
Warren, MI
1-star overall rating with 2-star inspections with $21,273 in total fines with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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