Inspection Reports for
Evergreen Health & Rehabilitation Center
19933 W 13 Mile Rd, Southfield, MI 48076, United States, MI, 48076
Back to Facility Profile15 CMS Surveys
Inspection Report — Sep 11, 2025
Plan of Correction
Date: Sep 11, 2025
Visit Reason
Plan of correction letter following a survey completed on 09/11/2025.
Findings
The facility was found to have multiple deficiencies including failure to conduct quarterly health care conferences, failure to administer medications as ordered, failure to obtain ordered laboratory tests, failure to provide assistive eating devices, and failure to maintain food safety standards.
Deficiencies (6)
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. The facility failed to ensure quarterly health care conferences were conducted for one resident (R154).
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. The facility failed to ensure lidocaine patches were available to administer for one resident (R6), resulting in multiple days of missed medication administration.
F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. The facility failed to ensure tube feeding and water flushes for hydration were administered per physician's orders for one resident (R23).
F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. The facility failed to ensure physician ordered laboratory tests (B12, Folate, TSH) were obtained for one resident (R81).
F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. The facility failed to ensure assistive devices for eating were provided to one resident (R17) according to their plan of care.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. The facility failed to prepare food in accordance with professional standards for food service safety, including undated opened containers, contaminated food preparation surfaces, and improper food temperature control.
Inspection Report — Aug 6, 2025
Complaint Investigation
Date: Aug 6, 2025
Visit Reason
Investigation of a complaint received on 2025-08-02 about failure to timely report a change in condition and timely transfer to a higher level of care.
Complaint Details
Failure to timely report change in condition and transfer to hospital: established.
Findings
One violation was established for failure to accurately assess, timely report a change in condition to the Physician, and timely transfer to a higher level of care for one resident.
Deficiencies (1)
F 0684 Provide appropriate treatment and care according to orders, resident's preferences and goals: the facility failed to accurately assess, timely report a change in condition to the Physician and timely transfer to a higher level of care for one resident after a fall, resulting in delayed hospital transfer and serious injuries.
Inspection Report — Apr 8, 2025
Complaint Investigation
Date: Apr 8, 2025
Visit Reason
Investigation of a complaint received on 2025-04-08 about injury care and incontinence care.
Complaint Details
Foot injury evaluation and treatment delay for R802: established. Timely incontinence care for R801: established.
Findings
Two deficiencies were found: failure to thoroughly evaluate and timely address a foot injury for one resident, resulting in delayed diagnosis and treatment of a comminuted avulsion fracture; and failure to provide timely incontinence care for another resident, who was left wet and soiled for approximately 11 hours.
Deficiencies (2)
F 0684 Provide appropriate treatment and care according to orders, resident's preferences and goals: the facility failed to thoroughly evaluate and timely address a foot injury for resident R802, resulting in delayed diagnosis and treatment of a moderately comminuted avulsion fracture to the heel, increased pain, and inability to fully participate in physical rehabilitation.
F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: the facility failed to provide timely incontinence care for resident R801, who was left wet and soiled for approximately 11 hours on 2/26/25.
Inspection Report — Feb 20, 2025
Complaint Investigation
Date: Feb 20, 2025
Visit Reason
Investigation of a complaint received on 2025-02-19 about psychotropic medication consent and pest control.
Complaint Details
Consent for psychotropic medications for resident R303: violation established. Pest control procedures for resident R305: violation established.
Findings
Two deficiencies were found: the facility failed to obtain consent from a legally authorized representative for psychotropic medications for one resident, and failed to follow pest control procedures resulting in bed bug infestations affecting one resident.
Deficiencies (2)
F 0551 Give the resident's representative the ability to exercise the resident's rights: the facility failed to ensure consent for psychotropic medications was obtained from the legally authorized representative for resident R303.
F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests: the facility failed to follow pest control procedures for resident R305, resulting in bed bug infestation and improper handling of contaminated clothing by staff.
Inspection Report — Dec 10, 2024
Complaint Investigation
Date: Dec 10, 2024
Visit Reason
Investigation of a complaint received on 2024-12-10 about resident abuse and neglect.
Complaint Details
Resident abuse by another resident: established. Failure to timely report neglect allegations: established.
Findings
Two violations of resident rights and abuse/neglect reporting requirements were established involving physical abuse between residents and failure to timely report neglect allegations.
Deficiencies (2)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: the facility failed to protect resident R803 from physical abuse by resident R804 who pushed R803 out of their wheelchair causing a fall.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report allegations of neglect involving resident R806 being left covered in dried feces and staff indicating care was not needed as the resident was dying.
Inspection Report — Aug 7, 2024
Complaint Investigation
Date: Aug 7, 2024
Visit Reason
Investigation of complaints received about infection control, resident rights, discharge planning, medication administration, wound care, and safety.
Complaint Details
Infection control failures including improper hand hygiene and PPE use: established. Resident rights violations including physician choice and room change notice: established. Medication administration errors: established. Wound care deficiencies: established. Unsafe discharge planning and fall assessment: established.
Findings
Multiple deficiencies were found including failure to maintain infection control protocols, failure to provide proper wound care and pressure ulcer care, failure to follow up on physician consults, failure to implement baseline care plans, failure to accurately document medication administration, failure to ensure safe discharge planning, failure to assess promptly after a fall, failure to maintain kitchen sanitation and dish machine sanitization, and failure to ensure residents' rights regarding visitation, room changes, and choice of attending physician.
Deficiencies (13)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: multiple residents were not treated with dignity during feeding and staff entered rooms without knocking or announcing themselves.
F 0555 Honor the resident's right to choose his or her attending physician: resident R288's choice to change doctors was not properly honored and physician Dr. F did not inform the facility when fired by the resident.
F 0559 Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made: resident R289 was moved multiple times without proper notice or explanation, including a move at 2:00 AM without adequate communication.
F 0563 Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing: facility restricted visitation hours to 8:00 AM to 8:00 PM with locked doors and no formal visitor policy, limiting residents' rights.
F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: resident R128's Do-Not-Resuscitate order was not implemented until after discharge.
F 0624 Prepare residents for a safe transfer or discharge from the nursing home: resident R29 experienced an unorganized and unsafe discharge process with lack of communication and care coordination.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: resident R287 receiving tube feeding had no baseline care plan for tube feeding.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: medications were inaccurately documented as given when refused (R27), and tube feeding orders for R287 were incomplete and not properly documented.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: wound care was not provided or documented for residents R337 and R120; failure to follow up on physician consult for resident R128.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: resident R337 had pressure ulcers with no wound care orders placed on admission.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: resident R29 was not promptly assessed after a fall and family was not notified.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: kitchen hood filters were greasy, dish machine temperatures were often below required sanitization levels, and dish machine was dirty with slime buildup.
F 0880 Provide and implement an infection prevention and control program: failure to ensure proper hand hygiene during meals, improper use of PPE and transmission-based precautions, and inappropriate room placement of residents on Contact Precautions (R288 and R289).
Inspection Report — Jul 8, 2024
Complaint Investigation
Date: Jul 8, 2024
Visit Reason
Investigation of a complaint received on 2024-05-27 about improper resident transfer and potential injury.
Complaint Details
Improper transfer causing resident knee pain: violation not established.
Findings
Based on resident functional mobility and staff interviews, the resident was not dropped to the floor during the transfer on 5/27/24. The facility identified a Past Non-Compliance regarding improper transfer and provided documentation of corrective actions and staff re-education.
Inspection Report — May 28, 2024
Complaint Investigation
Date: May 28, 2024
Visit Reason
Investigation of a complaint received on 2024-05-28 about facility cleanliness, safety, and medication cart security.
Complaint Details
Facility cleanliness and pest control: established. Unsafe storage of sharps and chemicals: established. Unsecured medication cart: established.
Findings
Multiple deficiencies were found related to facility cleanliness, pest control, unsafe storage of chemicals and sharps, and unsecured medication cart.
Deficiencies (2)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: the facility had soiled floors, walls, trash/debris throughout, broken chair and tile, unsecured sharps and chemicals, visible pests, and unclean shower rooms with mold and bugs.
F 0761 Ensure drugs and biologicals are stored securely: a medication cart on the Oakridge Unit was left unlocked and unattended with narcotics accessible.
Inspection Report — Mar 14, 2024
Complaint Investigation
Date: Mar 14, 2024
Visit Reason
Investigation of a complaint received on 2024-03-14 about medication administration, change of condition, wound care, supervision, weight monitoring, laboratory services, and rehabilitation services.
Complaint Details
Medication administration: established. Change of condition identification and communication: established. Pressure ulcer care and prevention: established. Supervision during medical appointment: established. Weight monitoring: established. Laboratory testing: established. Rehabilitation services: established.
Findings
Multiple deficiencies were found related to medication administration, failure to timely identify and communicate change of condition, inadequate wound care and monitoring, lack of supervision during medical appointment, failure to obtain weights as per policy, failure to complete ordered laboratory tests, and failure to provide therapy services as ordered.
Deficiencies (7)
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: facility nursing staff failed to administer prescribed pain medication Hydrocodone-Acetaminophen on multiple dates without documentation of reason.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: facility staff failed to timely identify and communicate a worsening change of condition for resident R801, resulting in hospitalization for severe sepsis and altered mental status.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: facility failed to assess, monitor, and treat pressure wounds for residents R801, R802, R803, and R804, resulting in unstageable sacral wound, deep tissue injury to right ear, stage III coccyx wound, and unstageable left heel wound.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: facility failed to provide supervision for resident R802 during a medical appointment, allowing the resident to be found unattended in the lobby with helmet on the floor.
F 0692 Provide enough food/fluids to maintain a resident's health: facility failed to obtain weights for resident R801 as required by facility policy, missing three weekly weights after admission.
F 0773 Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results: facility failed to complete ordered repeat CBC laboratory tests for resident R801 on multiple dates as directed by medical clinician.
F 0825 Provide or get specialized rehabilitative services as required for a resident: facility failed to provide physical and occupational therapy services five times per week as ordered for resident R803, with multiple days without therapy and no physician-approved change in frequency.
Inspection Report — Jan 30, 2024
Complaint Investigation
Date: Jan 30, 2024
Visit Reason
Investigation of complaints received regarding pain management and fall prevention.
Complaint Details
Pain management failure for resident R804: established. Unsafe wheelchair positioning and fall for resident R801: established.
Findings
Two deficiencies were found related to pain management and fall prevention resulting in minimal harm or potential for actual harm to residents.
Deficiencies (2)
F 0684 Provide appropriate treatment and care according to orders, resident's preferences and goals: the facility failed to assess and treat resident R804 who expressed pain, resulting in unrelieved pain and delayed medication administration.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to ensure safe positioning in a wheelchair with access to a call light for resident R801, resulting in a fall and head injury.
Inspection Report — Nov 15, 2023
Complaint Investigation
Date: Nov 15, 2023
Visit Reason
Investigation of a complaint received on 2023-11-14 about resident rights, professional standards, and therapeutic diet compliance.
Complaint Details
Resident rights violation regarding guardianship petition: established. Narcotic medication documentation discrepancies: established. Therapeutic diet noncompliance with prescribed texture: established.
Findings
Two deficiencies were found: the facility failed to timely obtain and acknowledge a resident's choice for health care decision making prior to petitioning for third party guardianship, and failed to ensure narcotic medications were documented accurately per professional standards. Additionally, the facility failed to provide food in the prescribed texture for a resident, increasing choking risk.
Deficiencies (3)
F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: the facility failed to timely obtain and acknowledge a resident's Durable Power of Attorney and improperly pursued third-party guardianship without educating the family, causing distress and unnecessary guardianship petition.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: the facility failed to document narcotic medication administration accurately, with discrepancies between Medication Administration Records and Controlled Drug Receipt forms for one resident.
F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs: the facility failed to provide food in the prescribed pureed texture for one resident, serving a piece of French Toast not properly pureed, increasing risk of choking and aspiration.
Inspection Report — Aug 17, 2023
Plan of Correction
Date: Aug 17, 2023
Visit Reason
Plan of correction accepted letter.
Findings
No health deficiencies found.
Inspection Report — Jun 29, 2023
Renewal
Date: Jun 29, 2023
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The report cites multiple deficiencies in resident care, medication management, infection control, dietary services, and facility sanitation, indicating non-compliance with professional standards and regulatory requirements.
Deficiencies (19)
F 0584: The facility failed to ensure a homelike dining experience for residents in the Anna's Place dining room as meals were served on cafeteria style trays without removing plates for consumption.
F 0658: Medication administration was not performed according to professional nursing standards for residents R90 and R253, including improper medication preparation and failure to observe residents during nebulizer treatments.
F 0660: The facility failed to ensure resident R156 was adequately prepared for discharge, lacking necessary medications and medical equipment upon discharge.
F 0677: The facility failed to provide consistent bathing and grooming care for residents R132, R153, R124, and R118, resulting in missed showers and unmet personal care needs.
F 0684: Resident R90's wound care was inconsistent and incomplete, including failure to perform wound assessments and administer treatments as ordered, and failure to discontinue obsolete orders for a Jackson Pratt drain.
F 0684: Facility failed to ensure neuro checks were completed following a resident's fall with head injury for resident R162, resulting in lack of documentation and potential risk.
F 0686: Resident R155 did not receive necessary treatments for pressure ulcers, resulting in worsening of a pressure wound to the spine.
F 0688: The facility failed to timely assess and provide appropriate assistive devices to maintain or improve mobility for resident R118, resulting in potential decline in mobility and dissatisfaction.
F 0689: The facility failed to perform safe wheelchair transport and adequately investigate an injury to resident R4, and failed to follow care plan for resident R110, resulting in injury and potential for further falls.
F 0690: The facility failed to timely review abnormal lab results for resident R58, resulting in delayed treatment of a urinary tract infection and hospitalization.
F 0692: The facility failed to ensure assessment and monitoring of hydration for resident R51, including communication gaps and inconsistent encouragement to drink fluids.
F 0698: The facility failed to ensure consistent communication between the hemodialysis center and the facility for resident R152, including missing communication forms.
F 0726: The facility failed to ensure two nursing staff (Nurse 'PP' and Nurse Aide 'N') had the appropriate competencies prior to working independently, including improper timing of competency evaluations.
F 0761: The facility failed to ensure appropriate storage and labeling of medications and treatments in medication and treatment carts, including unlocked carts and undated/opened medications.
F 0770: The facility failed to ensure physician ordered laboratory diagnostics were completed in a timely manner for resident R67.
F 0809: The facility failed to ensure meals were served in a timely manner and per scheduled times for residents in the secured unit, resulting in delayed meal service and dissatisfaction.
F 0812: The facility failed to maintain a sanitary kitchen environment, including improper food storage, labeling, soiled equipment, inadequate cleaning, and failure to monitor dish machine temperatures.
F 0847: The facility failed to ensure a legally authorized representative signed a binding arbitration agreement for resident R152, with no documentation of legal authority.
F 0880: The facility failed to ensure proper infection control practices for resident R148 on contact precautions, including failure to don PPE and improper sanitizing techniques.
Inspection Report — Jun 29, 2023
Renewal
Date: Jun 29, 2023
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
Multiple deficiencies were cited including failure to ensure a homelike dining experience, medication administration errors, inadequate discharge planning, inconsistent provision of activities of daily living, wound care deficiencies, failure to complete neuro checks after a fall, pressure ulcer care deficiencies, failure to assess and provide assistive devices for mobility, unsafe wheelchair transport, delayed treatment of urinary tract infection, inadequate hydration monitoring, inconsistent dialysis communication, staff competency issues, medication storage and labeling problems, untimely laboratory testing, delayed meal service, unsanitary kitchen conditions, failure to obtain legally authorized arbitration agreement signatures, and improper infection control practices.
Deficiencies (19)
F 0584 Honor the resident's right to a safe, clean and homelike environment: facility failed to ensure a homelike dining experience for residents in the Anna's Place dining room who were served meals on cafeteria trays without plates being removed.
F 0658 Ensure services meet professional standards: medication administration errors for residents R90 and R253 including improper medication preparation, leaving medications unattended, and failure to observe nebulizer treatments.
F 0660 Plan resident's discharge to meet goals and needs: failed to ensure resident R156 was adequately prepared for discharge with necessary pain medication and medical equipment.
F 0677 Provide care and assistance for ADLs: failed to ensure residents R132, R153, R124, and R118 consistently received showers, grooming, and assistance to get out of bed as scheduled or requested.
F 0684 Provide appropriate treatment and care: failed to perform consistent wound assessments and treatments for resident R90 including failure to discontinue orders for a Jackson Pratt drain no longer present.
F 0684 Failed to ensure neuro checks were completed following a fall with head injury for resident R162, resulting in delayed recognition of subdural hematoma and concussion.
F 0686 Provide appropriate pressure ulcer care: failed to initiate recommended wound treatments for resident R155, resulting in worsening of pressure ulcer to the spine.
F 0688 Provide appropriate care to maintain or improve range of motion and mobility: failed to assess and provide assistive devices such as assist bars or trapeze for resident R118 to improve bed mobility.
F 0689 Ensure safe wheelchair transport and accident prevention: failed to safely transport resident R4 in wheelchair resulting in injury and failed to investigate root cause; failed to provide two-person assistance for resident R110 resulting in fall from bed.
F 0690 Provide appropriate care for UTI: failed to timely review and act on abnormal urine culture results for resident R58 resulting in delayed treatment and hospitalization.
F 0692 Provide enough food/fluids to maintain resident's health: failed to ensure assessment and monitoring of hydration for resident R51 including lack of communication and inconsistent encouragement to drink fluids.
F 0698 Provide safe, appropriate dialysis care: failed to ensure consistent communication between dialysis center and facility for resident R152 including missed dialysis appointments and incomplete communication forms.
F 0726 Ensure nurses and nurse aides have appropriate competencies: nurse aide 'N' completed competency evaluation prior to nurse aide training program completion; nurse 'PP' completed competencies in one day without signing acknowledgement; new nurse assigned to high acuity unit without adequate training.
F 0761 Ensure drugs and biologicals are labeled and stored properly: multiple medication carts and treatment carts were unlocked and unattended; opened and undated insulin pens and eyedrops found in medication carts; insulin vial not refrigerated as required.
F 0770 Provide timely, quality laboratory services: failed to complete physician ordered CBC and BMP labs for resident R67 in a timely manner due to miscommunication and lack of lab request form.
F 0809 Ensure meals and snacks are served timely and per resident needs: meals served late on Anna's House secured unit resulting in delayed meal service and resident dissatisfaction.
F 0812 Procure food from approved sources and maintain sanitary kitchen: failed to maintain sanitary kitchen including improper food storage and labeling, contaminated and unsealed food items, soiled utensils and surfaces, unmonitored dish machine temperatures, and poor infection control practices by kitchen staff.
F 0847 Inform resident or representative choice to enter binding arbitration agreement and right to refuse: failed to ensure legally authorized representative signed binding arbitration agreement for resident R152; no documentation of legal authority for family member signature.
F 0880 Provide and implement infection prevention and control program: failed to follow contact precautions for resident R148 including failure to don gown and gloves, improper sanitizing of equipment, and failure to wait for sanitizer to dry before placing items back.
Inspection Report — Feb 2, 2023
Complaint Investigation
Date: Feb 2, 2023
Visit Reason
Investigation of complaints regarding resident rights, change in condition, wound care, stroke care, nutrition, dialysis coordination, and psychotropic medication use.
Complaint Details
Resident rights regarding code status: established. Change in condition notification: established. Wound care and treatment delays: established. Stroke care delay: established. Nutrition monitoring and intervention failure: established. Dialysis communication failures: established. Psychotropic medication misuse: established.
Findings
Multiple deficiencies were found including failure to consider resident wishes regarding code status, failure to notify legal guardian of change in condition, failure to provide timely and consistent wound care resulting in maggot infestation, delay in hospitalizing a resident with stroke symptoms, failure to monitor and intervene for significant weight loss, failure to ensure consistent coordination of dialysis care and communication, and failure to justify and monitor use of psychotropic medications with appropriate non-pharmacological interventions.
Deficiencies (7)
Failure to consider resident R818's expressed wishes for CPR before legal guardian changed code status to DNR.
Failure to notify legal guardian of resident R809's peg tube cellulitis and IV antibiotic treatment.
Failure to implement timely and consistent wound care for resident R804 resulting in maggot infestation of arterial ulcer on left great toe.
Failure to promptly send resident R807 to hospital after stroke symptoms were noted, resulting in delayed treatment.
Failure to consistently monitor weights and implement interventions for resident R803, resulting in significant weight loss and hospitalization for dehydration.
Failure to ensure consistent coordination and communication between facility and dialysis center for residents R818 and R811, including incomplete dialysis communication forms and conflicting code status information.
Failure to provide justification for PRN use of antipsychotic and antianxiety medications for resident R806, failure to identify targeted behaviors, and failure to implement person-centered non-pharmacological interventions prior to medication administration.
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