Corewell Health Rehab: Pressure Ulcer Care Failures - MI
By July 1, a physician classified it as a Stage 3 pressure ulcer.
A Stage 3 pressure ulcer has broken through the full thickness of the skin. The wound reaches into the fat layer beneath. It is not a rash or a scrape. It is a hole.
After that classification on July 1, the physician did not return to evaluate R801 until July 15. Inspectors asked the Director of Nursing whether any nurse had documented an assessment of the wound in those two weeks. The DON reviewed the clinical record and confirmed there was none.
The inspection, conducted August 14, 2025 at Corewell Health Rehab and Nursing Center-Commons Far, was triggered by a complaint. What inspectors found was a pattern, not an isolated lapse.
A second resident, identified as R803, was readmitted from the hospital on July 26. Staff identified a new wound to the coccyx, the bone at the base of the spine and one of the body's most vulnerable pressure points, on or around that date. The wound was not assessed by a physician until July 29, three days later. At that point it was classified as a Stage 2 pressure ulcer.
The facility's wound care nurse, identified as RN C, told inspectors that R803's wound should have been assessed immediately upon identification so that treatment could be implemented right away. She said it plainly, without hedging. She also noted she had not been the wound care coordinator at the time R801's situation unfolded.
The facility's own policy, dated April 2024, requires a head-to-toe skin assessment on admission and weekly thereafter. It requires complete documentation of wounds at least once a week, including measurements, tissue condition, wound bed appearance, drainage, and pain. It requires the plan of care to be updated with individualized interventions.
None of that happened for R801 between June 26 and July 1. None of it was documented between July 1 and July 15.
When inspectors asked the DON about the shower skin assessments completed during that period, the DON explained that staff only document new skin impairments on those forms, not worsening ones. When asked whether a worsening wound should appear somewhere in the record, the DON said that would be the treatment nurse's responsibility, not the person doing the skin assessment.
The treatment nurse had no orders to follow. There were no treatment orders for R801's coccyx until July 1, five days after the wound was first noted.
The facility's physician, identified as Physician B, came once a week. That schedule meant that after the July 1 visit, the next evaluation was July 15. Two weeks passed. A Stage 3 pressure ulcer sat without a single documented nursing assessment in between.
Inspectors rated this deficiency at the "Actual Harm" level. That designation means the failures caused real injury to at least one resident, not a theoretical risk of injury.
What the record shows, across two residents, is a wound care system that depended on a once-weekly physician visit and failed to function in the intervals between those visits. A skin tear noted on a Friday went without treatment orders until the following Tuesday. A wound that arrived with a patient from the hospital sat unexamined for three days. Weekly assessments that the facility's own policy required were either not completed or not documented.
R801's wound was a Stage 3 by the time anyone ordered treatment. The inspection record does not say what it looked like by July 15, when a physician finally returned.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Corewell Health Rehab & Nursing Center-commons Far from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 4, 2026 · Our methodology
Corewell Health Rehab & Nursing Center-Commons Far in Farmington Hills, MI was cited for violations during a health inspection on August 14, 2025.
By July 1, a physician classified it as a Stage 3 pressure ulcer.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.