Greenfield Rehab: Insulin Overdose Sent Resident to ICU - MI
The incident happened September 28, 2025 at Greenfield Rehab and Nursing Center. The nurse, identified in inspection records only as RN "C," had received three days of orientation and asked for a few extra days before working independently. The resident, identified as R801, had been ordered 3 units of insulin lispro. RN "C" drew up 100 units instead, misreading the medication's concentration as the dose. She noticed she had filled the entire syringe. She gave the injection anyway.
RN "C" wrote in her own incident report that she realized the error only when she went to chart the administration. She immediately told her preceptor, RN "D," who assessed the resident while RN "C" called 911.
R801's blood sugar was 124 before the injection. By the time EMS arrived and transported her, she had received oral glucose. Her blood sugar on arrival to the emergency department was 103. It did not hold. At 6:16 PM, a repeat check showed 48, a dangerous low. Staff gave her an injection of Dextrose 50% and her sugar climbed to 185. By 8:20 PM, the MICU team had evaluated her and taken her as an admission. She was placed on a dextrose drip and given a steroid medication.
The Director of Nursing, interviewed by inspectors on October 7, said RN "C" should have confirmed the dose when she noticed the syringe was full.
RN "C" had noticed. She told inspectors she thought it was a lot, but another resident on the same medication assignment was prescribed a very high insulin dose, and she assumed that explained it. She did not ask anyone.
The inspection cited actual harm affecting a small number of residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Greenfield Rehab and Nursing Center from 2025-10-07 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
Greenfield Rehab and Nursing Center in Royal Oak, MI was cited for violations during a health inspection on October 7, 2025.
The incident happened September 28, 2025 at Greenfield Rehab and Nursing Center.
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.