Greenfield Rehab And Nursing Center
Greenfield Rehab and Nursing Center in Royal Oak, MI — inspection on October 7, 2025.
Found 1 citation. 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.
Inspection Findings
care facility previously. RN ?C' reported she received three days of orientation where she shadowed
reported when she drew up R801's insulin, she thought it was a lot, but because another resident on
seek out clarification and verified the dose, but read the incorrect part of the order. On 10/7/25 at 9:36 AM, an interview was conducted with RN ?D' via the telephone.
When queried about what happened with R801's insulin on 9/28/25, RN ?D' reported RN ?C' came to her and said she thought she had a medication error.
When queried about the error, RN ?D' reported RN ?C' thought she gave 100 units of insulin to R801 instead of 3 units. RN ?D' reported R801 was assessed and blood sugar was rechecked. At that time, R801's blood sugar remained at baseline. RN ?D' reported RN ?C' called the physician and sent R801 out 911. A review of an Incident Report dated 9/28/25 at 5:00 PM, completed by RN ?C', revealed a statement by RN ?C' taken on 10/1/25 that noted, .I took the pt (patient's) blood 124. I read the order thinking the medication strength was the dose to be given, drew up 100 units in the insulin syringe instead of the 3 units ordered. I administered the insulin in her left arm. I went to chart administration was complete and realized I had made a medication error. I immediately notified (RN ?D') who had been my preceptor and called 911 while (RN ?D') assessed the resident. I then retook the residents blood sugar while (RN ?D') notified the DON (Director of Nursing).
EMS (Emergency Medical Services) arrived, I called the Provider oncall and notified them patient was being transferred due to being given 100 units of insulin.On 10/7/25 at approximately 12:45 PM, an interview was conducted with the DON.
When queried about the medication error made by RN ?C', the DON reported RN ?C' should have confirmed the insulin dose when she noticed she filled up the whole syringe. A review of R801's hospital records revealed the following: An ED (Emergency Department) Provider Note dated 9/28/25 revealed the following documentation, .5:26 PM.Patient.may have received excessive insulin in error at nursing facility.
Per EMS she accidentally received 100 units lispro instead of 3 units.
Her initial blood glucose on arrival to out emergency department was 103, but she did receive some oral glucose prior to arrival.6:16 PM Repeat POC (point-of-care) glucose 48 (low). D50 (Dextrose 50%) given with improvement to 185.
Will admit for serial blood sugar checks and management.8:20 PM MICU (Medical Intensive Care Unit) evaluated patient, and they will admit her to the MICU admission at this time.
Switched dextrose gtt (glucose tolerance test) to D10 (Dextrose 10%) and solu-cortef (steroid medication) given.A review of a facility policy titled, Medication Administration, dated 8/7/23, revealed, in part, the following, .Medications are administered in accordance with the following rights of medication administration.Right dose.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.