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Complaint Investigation

Corewell Health Rehab & Nursing Center-commons Far

February 25, 2026 · Farmington Hills, MI · 21450 Archwood Circle
Citations 2
CMS Rating 4/5
Beds 179
Provider ID 235462
Healthcare Facility
Corewell Health Rehab & Nursing Center-commons Far
Farmington Hills, MI  ·  View full profile →
Inspection Summary

Corewell Health Rehab & Nursing Center-Commons Far in Farmington Hills, MI — inspection on February 25, 2026.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies

Based on interview and record review, the facility failed to implement safety interventions to prevent

the emergency room where it was discovered R803 sustained a left tibia (shin bone) fracture, a contusion (bruise) to the left upper extremity, and an abrasion to the right upper extremity.

Findings include: On 2/24/26 at 9:00 AM, a review of a nursing progress note dated 11/29/25 at 12:48 AM entered into the record by Nurse 'E' was reviewed and read, Note Text: Writer was called by caregiver (Certified Nurse Aide 'D') that resident fell to the floor.

Upon rushing to the room, resident was laying on the floor next to bed with body in curled position leaning towards her right side, bed was in high position with the bed unlocked.

The CNA (Certified Nurse Aide) said she rolled the resident towards herself but unfortunately the bed rolled backwards and resident fell forward to the floor.

Resident sustained hematoma to the forehead, skin tear left deltoid and right elbow.

Complained of pain to the left foot .Resident was transferred to hospital via 911 . On 2/24/26 at 9:10 AM, a review of a facility provided investigation file for a fall sustained by R803 was conducted.

The file contained a document titled, (Facility Name) POST FALL ANALYSIS AND INVESTIGATION that read, .WHAT NEW INFORMATION WAS DISCOVERED: Staff rolled the patient towards her, the bed rolled away due to unlocked wheels, that leads {sic} to her fall .IMMEDIATE INTERVENTION WAS PUT IN PLACE: .patient was sent to the hospital .ROOT CAUSE: .Staff rolled the patient towards her, the bed rolled away due to unlocked wheels, that leads {sic} to her fall .CONCLUSIONS & RECOMMENDATIONS: Staff education completed to make sure that the bed wheels are locked before making any transfers or repositioning to prevent a fall .

New onset or worsening of acute illness that may affect resident's cognitive or physical abilities: Left tibia fracture acquired .Continued review of the investigation file revealed a signed, written statement from CNA 'D' that read, Around 4:50 pm I was doing care on the resident. I rolled her from the wall into my body.

The resident's bed slid and she fell onto her side .There was bruising to the head, arm and leg. A review of a typed document contained in the file read, Investigative Overview .The facility determined the accident was caused by (CNA 'D')'s priority to care for (R803) without locking the wheels of the bed .

Further review of the file revealed another typed document that read, Below is the nurse managers {sic} investigative report . (Hospital Name) Hospital Report: Imaging test: .diagnosis: Closed displaced fracture of left tibia .other findings: 3. contusion of left upper extremity 4. abrasion of the right upper extremity .HOSPITAL ASSESSMENT AND PLAN: orthopedic surgery consulted, splint applied to the left leg, pain management, non weightbearing {sic} LLE (Left Lower Extremity) at this time . On 2/24/26 at 2:30 PM, an interview was conducted with the facility's Administrator regarding the investigation file.

They were asked about R803's fall and confirmed CNA 'D' did not have the wheels on the bed locked when they repositioned R803 causing the bed to roll away and R803 falling from the bed to the floor.A review of a facility provided policy titled, Resident Safety and Precautions revised 4/2024 was conducted and read, 1.

Purpose: To outline resident safety standards and describe resident precautions and the associated interventions .3.1 Resident Safety Standards .3.1.2.1 Bed wheels locked .

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

235462 02/25/2026

Corewell Health Rehab & Nursing Center-Commons Far 21450 Archwood Circle Farmington Hills, MI 48336

that read, Note Text: writer rechecked resident's blood sugar and the reading was Hi {sic} 12 units of

into the record by Nurse 'C' on 12/10/25 at 3:50 AM that read, Note Text: (Ambulance) called for

conducted and read the following, .CHIEF COMPLAINT: HIGH BLOOD SUGAR and ALTERED MENTAL STATUS .HISTORY OF PRESENT ILLNESS: .Per EMS .They report the patient on their arrival was receiving D5 fluid hydration .Patient presents with HIGH BLOOD SUGAR Per EMS pt. was found to be hyperglycemic (high blood sugar) at (Facility Name) and staff administered D5 infusion, unk (unknown) amount of insulin given by nurse POC (Point of Care glucose reading from glucose monitor) 300's (glucose levels) . On 2/25/26 at 11:00 AM, an interview was conducted with Physician Assistant (PA) 'A'.

They were asked if they were aware R802's blood glucose level was 732 prior to them ordering D5% 0.45% NS for intravenous infusion.

They said they were not aware of the elevated glucose level and if they were, they would not have ordered an IV fluid with dextrose.

They were then asked if they, themselves reviewed the labs on 12/8/25 prior to ordering the IV fluid. PA 'A' reviewed their progress note for their visit to R802 on 12/8/25 and said they did not document they reviewed the labs.

They were then made aware R802 received a continuous infusion of D5% 0.45% NS from 12/8/25 to 12/10/25 and they subsequently were transferred to the emergency room for hyperglycemia. PA 'A' was then asked what should have happened and said they should have reviewed the labs prior to ordering the IV fluids. On 2/25/26 at approximately 11:30 AM, an interview was conducted with the facility's Director of Nursing (DON) regarding the concern.

They indicated PA 'A's order for D5% 0.45% NS could have been questioned by the nurse who received the critically high glucose level and implemented PA 'A's order for D5% 0.45% NS. A review of a facility provided policy titled, Role and Responsibilities of Attending Physicians and Advanced Practice Providers-Continuing Care (Rehab and Nursing Centers) effective 4/2024 was conducted and read, .During a physician or advanced practice provider visits, each resident/patient's overall condition will be determined, including: Status of specific medical issues or diagnoses through proper assessment, review of patient information, and conversations with clinical team members .Review laboratory and other diagnostic test with provider visit .Abnormal test results will be analyzed, and a medical rationale will be documented, in addition to rationale for subsequent interventions or decisions not to intervene based on results .

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Farmington Hills, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Corewell Health Rehab & Nursing Center-Commons Far or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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