Mission Point Rehab: Immediate Jeopardy Abuse - MI
The fall happened on September 28, 2025. The resident, identified in inspection records as R901, required extensive or total assistance for nearly all daily activities. The Kardex, a bedside care reference document, specified two caregivers for toileting. A physical therapy discharge summary from August 2025 noted the resident had been discharged from therapy at maximum assistance for bed mobility, with a recommendation for 24-hour care.
CNA A, the nursing assistant providing care at the time, told inspectors on December 23 that they were changing R901's brief alone when the resident rolled off the bed. The CNA said they understood two-person assistance was required for bed mobility, but not for toileting. The care was happening in the bed.
The facility investigated. The administrator told inspectors the investigation found that CNA A had not used the proper assistance level. But when inspectors showed the administrator the Kardex, which documented two-person assistance for toileting specifically, the administrator said they had only identified the one-person intervention during the review. Shown the entry directly, the administrator offered no response. No further explanation was provided before the inspection closed.
The interdisciplinary team, inspectors found, had failed to catch that two conflicting care instructions existed in the record simultaneously, and failed to ensure the instructions were clear enough to prevent what happened.
The facility had trained CNA A individually. Records from a one-on-one in-service noted that the Kardex contains all pertinent information about how to care for a resident, and that it is updated when patient needs change. The Kardex on September 28 required two people. One person was there.
R901 was on the floor.
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: 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: August 9, 2026 · Our methodology
Harmony Village of Clawson in Clawson, MI was cited for abuse-related 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.