Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

B+
Grade
57
Score
CMS Ratings
12.5/22
Staffing Quality
10.1/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
6.0/10

Current Availability Estimate

Occupancy Rate91.1%
172
Total Beds
157
Occupied
15
Available

Basic Information

Address:

19933 West Thirteen Mile Road

Southfield, MI 48076

Number of Beds:

172

Estimated Occupancy:

91% (~15 available)

Chain:

OPTALIS HEALTH & REHABILITATION

Quality Ratings

Overall Rating:3/5 Stars
Health Inspection:2/5 Stars
Staffing Rating:2/5 Stars
Quality Measures:5/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

235582

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Below Average

This Facility

0.46

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Average

This Facility

3.91

hours

National Avg

3.89

hours

Breakdown:

RN: 0.46hLPN: 1.48hAide: 1.97h

Staff Turnover Rate

Annual nursing staff turnover

Average

This Facility

46.0%

National Avg

46.6%

RN Turnover: 39.1%

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Total Deficiencies

150

Inspections

12

High

14

Apr 8, 2025 - Health Survey

4 deficiencies cited

Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Apr 30, 2025From Complaint
High - Widespread PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Apr 30, 2025From Complaint
High - Widespread PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Apr 30, 2025From Complaint
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Apr 30, 2025From Complaint

Feb 20, 2025 - Health Survey

4 deficiencies cited

Medium - PatternTag F0551

Resident Rights Deficiencies

Give the resident's representative the ability to exercise the resident's rights.

Corrected: Mar 11, 2025From Complaint
Medium - PatternTag F0551

Resident Rights Deficiencies

Give the resident's representative the ability to exercise the resident's rights.

Corrected: Mar 11, 2025From Complaint
Medium - PatternTag F0925

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected: Feb 6, 2025From Complaint
Medium - PatternTag F0925

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected: Feb 6, 2025From Complaint

Dec 10, 2024 - Health Survey

4 deficiencies cited

Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Dec 30, 2024From Complaint
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Dec 30, 2024From Complaint
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Dec 30, 2024From Complaint
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Dec 30, 2024From Complaint

Aug 7, 2024 - Health Survey

26 deficiencies cited

Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Sep 17, 2024
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Sep 17, 2024
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Sep 17, 2024
Medium - PatternTag F0555

Resident Rights Deficiencies

Honor the resident's right to choose his or her attending physician.

Corrected: Sep 17, 2024
Medium - PatternTag F0559

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Corrected: Sep 17, 2024
Medium - PatternTag F0563

Resident Rights Deficiencies

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Corrected: Sep 17, 2024
Medium - PatternTag F0578

Resident Rights Deficiencies

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.

Corrected: Sep 17, 2024
Medium - PatternTag F0624

Resident Rights Deficiencies

Prepare residents for a safe transfer or discharge from the nursing home.

Corrected: Sep 17, 2024
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Sep 17, 2024
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Sep 17, 2024
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Sep 17, 2024
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Sep 17, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Sep 17, 2024
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Sep 17, 2024
Medium - PatternTag F0555

Resident Rights Deficiencies

Honor the resident's right to choose his or her attending physician.

Corrected: Sep 17, 2024
Medium - PatternTag F0559

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Corrected: Sep 17, 2024
Medium - PatternTag F0563

Resident Rights Deficiencies

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Corrected: Sep 17, 2024
Medium - PatternTag F0578

Resident Rights Deficiencies

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.

Corrected: Sep 17, 2024
Medium - PatternTag F0624

Resident Rights Deficiencies

Prepare residents for a safe transfer or discharge from the nursing home.

Corrected: Sep 17, 2024
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Sep 17, 2024
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Sep 17, 2024
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Sep 17, 2024
Medium - PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Sep 17, 2024
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Sep 17, 2024
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Sep 17, 2024
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Sep 17, 2024

Jul 8, 2024 - Health Survey

2 deficiencies cited

Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jun 11, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jun 11, 2024From Complaint

May 28, 2024 - Health Survey

4 deficiencies cited

Medium - PatternTag F0584

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.

Corrected: Jun 14, 2024From Complaint
Medium - PatternTag F0761

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.

Corrected: Jun 14, 2024From Complaint
Medium - PatternTag F0761

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.

Corrected: Jun 14, 2024From Complaint
Medium - PatternTag F0584

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.

Corrected: Jun 14, 2024From Complaint

Mar 14, 2024 - Health Survey

14 deficiencies cited

High - Widespread PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Apr 2, 2024From Complaint
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Apr 2, 2024From Complaint
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Apr 2, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Feb 27, 2024From Complaint
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Apr 2, 2024From Complaint
High - Widespread PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Apr 2, 2024From Complaint
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Apr 2, 2024From Complaint
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Apr 2, 2024From Complaint
Medium - PatternTag F0825

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

Corrected: Apr 2, 2024From Complaint
Medium - PatternTag F0773

Administration Deficiencies

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Corrected: Apr 2, 2024From Complaint
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Apr 2, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Feb 27, 2024From Complaint
Medium - PatternTag F0825

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

Corrected: Apr 2, 2024From Complaint
Medium - PatternTag F0773

Administration Deficiencies

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Corrected: Apr 2, 2024From Complaint

Jan 30, 2024 - Health Survey

4 deficiencies cited

Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Feb 15, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Feb 15, 2024From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Feb 15, 2024From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Feb 15, 2024From Complaint

Nov 15, 2023 - Health Survey

6 deficiencies cited

Medium - PatternTag F0578

Resident Rights Deficiencies

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.

Corrected: Dec 8, 2023From Complaint
Medium - PatternTag F0578

Resident Rights Deficiencies

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.

Corrected: Dec 8, 2023From Complaint
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Dec 8, 2023From Complaint
Medium - PatternTag F0805

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected: Dec 8, 2023From Complaint
Medium - PatternTag F0805

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected: Dec 8, 2023From Complaint
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Dec 8, 2023From Complaint

Jun 29, 2023 - Health Survey

36 deficiencies cited

Medium - PatternTag F0761

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.

Corrected: Jul 28, 2023From Complaint
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jul 28, 2023From Complaint
High - Widespread PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0698

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0726

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0761

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.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0770

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0809

Nutrition and Dietary Deficiencies

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0847

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0584

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.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0660

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Jul 28, 2023From Complaint
High - Widespread PatternTag F0686

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jul 28, 2023From Complaint
High - Widespread PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0698

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0726

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0770

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0809

Nutrition and Dietary Deficiencies

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0847

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0584

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.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0660

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Corrected: Jul 28, 2023From Complaint
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Jul 28, 2023From Complaint

Feb 2, 2023 - Health Survey

12 deficiencies cited

Medium - PatternTag F0551

Resident Rights Deficiencies

Give the resident's representative the ability to exercise the resident's rights.

Corrected: Feb 28, 2023From Complaint
Medium - PatternTag F0551

Resident Rights Deficiencies

Give the resident's representative the ability to exercise the resident's rights.

Corrected: Feb 28, 2023From Complaint
High - Widespread PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Feb 28, 2023From Complaint
Medium - PatternTag F0698

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected: Feb 28, 2023From Complaint
Medium - PatternTag F0758

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.

Corrected: Feb 28, 2023From Complaint
Medium - PatternTag F0580

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected: Feb 28, 2023From Complaint
High - Widespread PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Feb 28, 2023From Complaint
Medium - PatternTag F0758

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.

Corrected: Feb 28, 2023From Complaint
Medium - PatternTag F0698

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected: Feb 28, 2023From Complaint
High - Widespread PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Feb 28, 2023From Complaint
High - Widespread PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Feb 28, 2023From Complaint
Medium - PatternTag F0580

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected: Feb 28, 2023From Complaint

May 26, 2022 - Health Survey

34 deficiencies cited

Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Jul 6, 2022
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Jul 6, 2022
Medium - PatternTag F0685

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Corrected: Jul 6, 2022
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected: Jul 6, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jul 6, 2022
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Jul 6, 2022
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jul 6, 2022
Medium - PatternTag F0693

Quality of Life and Care Deficiencies

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.

Corrected: Jul 6, 2022
Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected: Jul 6, 2022
Medium - PatternTag F0761

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.

Corrected: Jul 6, 2022
Medium - PatternTag F0803

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected: Jul 6, 2022
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Jul 6, 2022
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Jul 6, 2022
Medium - PatternTag F0880

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Corrected: Jul 6, 2022
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Jul 6, 2022
Medium - PatternTag F0803

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected: Jul 6, 2022
Medium - PatternTag F0761

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.

Corrected: Jul 6, 2022
Medium - PatternTag F0725

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected: Jul 6, 2022
Medium - PatternTag F0693

Quality of Life and Care Deficiencies

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.

Corrected: Jul 6, 2022
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Jul 6, 2022
Medium - PatternTag F0690

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected: Jul 6, 2022
Medium - PatternTag F0688

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected: Jul 6, 2022
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Jul 6, 2022
Medium - PatternTag F0685

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Corrected: Jul 6, 2022
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Jul 6, 2022
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Jul 6, 2022
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Jul 6, 2022
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Jul 6, 2022
Medium - PatternTag F0578

Resident Rights Deficiencies

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.

Corrected: Jul 6, 2022
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Jul 6, 2022
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Jul 6, 2022
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Jul 6, 2022
Medium - PatternTag F0578

Resident Rights Deficiencies

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.

Corrected: Jul 6, 2022
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Jul 6, 2022

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

1 penalty in the past 3 years

Total fines: $28,815

FineMarch 14, 2024

$28,815

Data processed: August 1, 2026

About Penalties: This data comes from CMS (Centers for Medicare & Medicaid Services) and shows fines and payment denials issued for health and safety violations. Penalties indicate serious deficiencies that required enforcement action.

Key Highlights

Low Staff Turnover
46.0% (national avg: 46.6%)
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Beds Available
Approximately 15 beds potentially available
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Part of Healthcare Chain
OPTALIS HEALTH & REHABILITATION

Frequently Asked Questions

What is the quality rating for Evergreen Health and Rehabilitation Center?

Evergreen Health and Rehabilitation Center has an overall CMS rating of 3 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

Evergreen Health and Rehabilitation Center has 172 certified beds. The facility averages 157 residents per day, with an occupancy rate of approximately 91%.

What type of ownership does this facility have?

This facility is for profit - corporation owned. It is part of the OPTALIS HEALTH & REHABILITATION network.

How can I contact Evergreen Health and Rehabilitation Center?

You can call Evergreen Health and Rehabilitation Center at (248)203-9000. The facility is located at 19933 West Thirteen Mile Road, Southfield, MI 48076.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

Important Considerations for This Facility

Based on this facility's data, we recommend reading these guides to understand what to look for:

📚 Learn How to Evaluate Facilities

Understanding quality metrics helps you make better decisions. Check out these data-driven guides: