Martha T Berry MCF: Dementia Resident Fall Violation - MI
The aide, identified in inspection records as AA C, had known the resident, referred to as R901, for about two years. On the day of the fall, AA C spotted R901 coming up the hallway pushing a bedside tray table, which AA C considered a fall hazard. AA C met R901 roughly twenty feet from her room, took the tray table away, and told R901 to grip the handrail while AA C went to retrieve the resident's walker.
AA C never made it to the walker. Before retrieving it, AA C heard a loud noise from the hallway. R901 had already fallen.
The unit manager, UM D, told inspectors that R901 frequently walked away from her walker and needed redirection because of poor safety awareness. That history was not new information. It was the baseline condition staff worked with every day.
UM D said the proper response would have been to secure R901 with a gait belt and assist her to a seated position. Instead, AA C left her standing alone at a railing. "It was the wrong decision," UM D told inspectors. "You cannot leave a dementia resident alone."
The director of nursing told inspectors that after the fall, staff provided AA C with education that included a blunt lesson about dementia care: you can never tell a person with dementia to stay somewhere and expect them to remember it a moment later. AA C acknowledged receiving that education. AA C also acknowledged, when inspectors interviewed her on November 10, that she should never have left the resident.
The administrator, interviewed that same afternoon, acknowledged that AA C had the opportunity to intervene appropriately and did not.
What makes the sequence difficult to read past is its brevity. AA C did not leave the building. AA C did not become distracted by another emergency. AA C walked to a room roughly twenty feet away to return a piece of furniture. R901 fell in the time that took.
The facility's own fall prevention policy, last approved in July 2025, states that supervision is an intervention and a means of mitigating fall risk, and that adequate supervision is based on each resident's individual assessed needs. R901's assessed need, as UM D described it, was continuous redirection due to poor safety awareness. She was a resident who walked away from her walker. She was a resident staff knew could not be relied upon to stay where she was told.
None of that was unknown to AA C. AA C had worked alongside R901 for two years.
The inspection was triggered by a complaint and conducted on November 10, 2025. CMS rated the violation at the actual harm level, meaning inspectors determined R901 suffered real injury as a result of what happened, not merely that she was placed at risk.
The fall itself is the end of what the inspection report documents. What R901's injuries were, how long her recovery took, whether her mobility changed afterward, the report does not say. What it does say is that an aide who knew her, who recognized she was in danger, who made a decision intended to help her, left her alone in a hallway for the seconds it took to walk twenty feet, and that was enough.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Martha T Berry Mcf from 2025-11-10 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 22, 2026 · Our methodology
Martha T Berry MCF in Mount Clemems, MI was cited for violations during a health inspection on November 10, 2025.
The aide, identified in inspection records as AA C, had known the resident, referred to as R901, for about two years.
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.