Harmony Village Of Clawson
Harmony Village of Clawson in Clawson, MI — inspection on December 26, 2025.
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.
Inspection Findings
jeopardy to resident health or safety
with R910 on top of them, in between 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 R909's sexual capacity assessment conclusion and how 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 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 R909 and 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 R909's decision making capacity evaluation dated 1/19/22 had documented 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 R909 in bed with 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 R910 but knew that they had been wanting to be with 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 R910 in their room but did not find them in it and subsequently ran down to R909's room and found them both in bed with pants off with R910 in between R909's legs with R909's legs in the air.
Nurse E reported they immediately separated both residents.
Nurse E was queried if R909 was aware of the sexual encounter with R910 and what had occurred between them and they reported R909 had no recollection of what had occurred two minutes after the incident was discovered.
Nurse E was queried if 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 R909 had severe dementia and did not know what they were doing or where they were.
Nurse E was queried if R909 was a vulnerable target for sexual encounters and they reported that they were due to their dementia.
On 12/2[TRUNCATED]
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Mission Point Nursing & Physical Rehabilitation Ce
535 N Main Clawson, MI 48017
SUMMARY STATEMENT OF DEFICIENCIES
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 R901's fall.
The Administrator stated they completed the investigation into 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.
Facility ID: