Mission Point Rehab: Resident Harm, Safety Hazards - MI
The fall happened on September 28, 2025. The resident, identified in inspection records as R901, required maximum assistance with bed mobility and two caregivers for all incontinence care, according to their Kardex, the document staff use as a daily care reference. A physical therapy discharge summary from August 2025 had recommended 24-hour care. The resident was, by every clinical measure on file, someone who needed two people present.
CNA A was alone anyway.
In an interview on December 23, the aide told inspectors they understood the resident needed two-person assistance for bed mobility, but not for toileting. The distinction did not hold up. CNA A was performing incontinence care in the resident's bed when R901 rolled off. The Kardex listed two caregivers as required for both tasks.
The facility completed its own investigation and found that CNA A had not used the proper assistance level. That was accurate, as far as it went. But when inspectors showed the administrator the care plan, which contained two separate interventions both specifying two-person assistance, the administrator acknowledged they had only identified one of them during the review. The Kardex for September 28, which also documented the two-person toileting requirement, was reviewed with the administrator on the spot. No response was provided. No additional explanation or documentation followed before the survey closed.
The interdisciplinary team, inspectors noted, had failed to recognize that two overlapping interventions existed for toileting, and had not resolved the contradiction before the fall or after it.
CMS cited the deficiency at the actual harm level.
R901 remains a resident at the facility.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harmony Village of Clawson from 2025-12-26 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: June 20, 2026 · Our methodology
Harmony Village of Clawson in Clawson, MI was cited for violations during a health inspection on December 26, 2025.
The fall happened on September 28, 2025.
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.