Harmony Village Of Clawson

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

with Resident R910 on top of them, in between Resident R909's legs and both had all their pants removed and were unclothed from the waist down. The Administrator reported that once the residents were found by Nurse E they were separated immediately. The Administrator was queried regarding Resident R909's sexual capacity assessment conclusion and how Resident R909 was deemed having the capacity to consent to sexual encounters with other residents when they were severely cognitively impaired and not able to remember they had the encounter or who they had the encounter with as well as not having the mental capacity to understand the risks and consequences of sexual encounters and they reported that they understood the concern, but that the Physician had done the sexual capacity assessment. At that time, the Administrator was queried regarding

the status of Resident R909 having sexual encounters with residents in the facility and they indicated they were not encouraging it, but it was permitted by facility staff for both Resident R909 and Resident R910 to engage in sexual activity and

the facility staff would not intervene. The Administrator was queried regarding the policy pertaining to sexual consent, that referenced the need for both the decision-making capacity evaluation and capacity for sexual consent evaluations to be done and that Resident R909's decision making capacity evaluation dated 1/19/22 had documented Resident R909 was mentally incapacitated to make informed decisions, and they indicated that they understood the discrepancy. On 12/23/25 at approximately 2:57 p.m., during a conversation with Nurse E, Nurse E was queried regarding finding Resident R909 in bed with Resident R910, unclothed from the waist down on 11/28/25.

Nurse E reported they were on a split hall that day and could not supervise Resident R910 but knew that they had been wanting to be with Resident R909. Nurse E Stated that it was the midnight shift when it occurred, and that they came back up to the unit and looked for Resident R910 in their room but did not find them in it and subsequently ran down to Resident R909's room and found them both in bed with pants off with Resident R910 in between Resident R909's legs with Resident R909's legs in the air. Nurse E reported they immediately separated both residents. Nurse E was queried if Resident R909 was aware of the sexual encounter with Resident R910 and what had occurred between them and they reported Resident R909 had no recollection of what had occurred two minutes after the incident was discovered.

Nurse E was queried if Resident R909 had the capacity to understand risks/actions and consequences of having sexual encounters with other residents and they reported they did not. Nurse E further reported that Resident R909 had severe dementia and did not know what they were doing or where they were. Nurse E was queried if Resident R909 was a vulnerable target for sexual encounters and they reported that they were due to their dementia.

On 12/2[TRUNCATED]

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Mission Point Nursing & Physical Rehabilitation Ce

535 N Main Clawson, MI 48017

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

following . Dependent with 1 staff, size medium white (initiated 6/9/25). revealing contradicting information.

A review of Resident R901's Kardex Report for 9/28/2025, documented in part . TOILETING- Two caregivers at all times to complete incontinence care. I am an extensive/total assist with toileting. BED MOBILITY- Extensive assist 2 staff. Further review of the Kardex noted multiple documentation of the resident to be extensive assistance for mostly all ADLs. On 12/23/25 at 11:04 AM, the Physical Therapy (PT) & Occupational Therapy (OT) assessments last completed before Resident R901's fall on 9/28/25 was requested from Physical Therapist (PT) B and the facility's Administrator. A review of a PT Discharge Summary dated 6/10/2025-8/6/2025, documented in part . Bed Mobility. Baseline (6/10/2025)- Total Dependence w/o (without) attempts to initiate. Previous (6/24/25)- Total Dependence w/o (without) attempts to initiate.

Discharge (8/6/2025)- Max (A)- (maximum assistance). Discharge Recommendations: 24 hour care.On 12/23/25 at 12:13 PM, CNA A (the CNA that provided care for Resident R901 at the time of the fall) was interviewed and asked about the incident. CNA A explained they were changing the resident's brief by themselves when Resident R901 rolled off the bed and onto the floor. When asked why they were by themselves when providing care to Resident R901, CNA A stated they knew that the resident needed a two person care for bed mobility but not for toileting. Despite CNA A verbalizing that they were providing incontinence care in Resident R901's bed, CNA A proceeded to provide care with a one person assist.A review of a ONE-ON-ONE IN-SERVICE provided noted in part . Kardex- The Kardex is where you will find all of the pertinent information about how to take care of the resident. The Kardex stems from the care plans which are reviewed and updated as needed with changes in patient needs and incidents.Further review of the facility's investigation revealed the Interdisciplinary team failed to identify the two interventions implemented at the same time for Toileting and

the failure to ensure clear and precise interventions for assistance levels were implemented to ensure the residents safety and to prevent preventable accidents. Review of a facility policy titled Incident Reporting Accidents and Supervision revised 8/24 documented in part . The resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. This includes. Implementing interventions to reduce hazard(s) and risk(s). Monitoring effectiveness and modifying interventions when necessary. The facility shall establish and utilize a systematic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. the process of examining data to identify specific hazards and risks and to develop targeted interventions to reduce the potential for accidents. Interdisciplinary involvement is a critical component of

this process. using specific interventions to try to reduce a resident's risks from hazards in the environment.On 12/23/25 at 12:50 PM, the Administrator was interviewed and asked about the fall and investigation into Resident R901's fall. The Administrator stated they completed the investigation into Resident R901's fall and identified that CNA A did not properly understand the toileting and bed mobility tasks. When showed the ADL care plan with two interventions implemented for toileting, despite an intervention for toileting and bed mobility to be documented as a two person assistance, the Administrator stated they had only identified the one person assistance intervention during their investigation. The Administrator stated they identified the cause of (CNA A) to have not used the proper assistance level needed. The Kardex for 9/28/25 was reviewed with the Administrator that also noted a two person assistance with toileting care and no response was provided. No further explanation or documentation was provided by the end of the survey.

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