Martha T Berry Mcf
Martha T Berry MCF in Mount Clemems, MI — inspection on November 10, 2025.
Found 1 citation. 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
falls at the facility.
The DON reported recent education was provided for activity aide (AA C). AA C had intercepted a resident (R901) walking down the hallway holding onto a bedside table. AA C took the tray table from R901 and instructed R901 to grab the handrail and to stay there.
When AA C turned away to return the tray table to the resident's room, R901 walked away from the handrail.
The resident then fell.
The DON further reported the education to AA C included, you can never tell a demented person to stay and expect them to remember a moment later. On 11/10/25 at 12:41 PM, AA C reported they had known R901 for around two years. AA C recounted the incident with R901 and reported they had been on their way to dietary when they observed R901 coming up the hall to the nurse's station pushing a bedside tray table. AA C met up with R901 in the hallway around twenty feet or so from the resident's room. AA C felt R901 was in danger while using the bedside table and instructed R901 to hold onto the handrail while they went and retrieved the resident's walker. AA C returned the bedside table to the room and before they retrieved the walker they heard a loud noise. AA C exited R901's room to find that R901 had fallen. AA C acknowledged they received education after the incident, to never leave the resident. On 11/10/25 at 3:10 PM, Unit Manager UM D was asked about R901's fall and reported R901 would frequently walk away from their walker and need redirection due to poor safety awareness. UM D recounted the fall and reported staff AA C was seen walking from the nurse station while R901was walking up the hallway from their room. AA C had R901 stand at the railing and holding on. AA C then went to R901's room and as AA C walked away, R901 turned and walked approximately 10-15 steps caught their foot and fell. UM D reported they provided education to AA C which included any resident seen walking without their device should be secured with a gait belt and assisted to a seated position. UM D reported It was the wrong decision.
You cannot leave a dementia resident alone.On 11/10/25 at 5:15 PM, the Administrator acknowledged AA C had the opportunity to intervene appropriately and did not. A review of the facility policy titled, Falls - Clinical Protocol with approved date of 07/09/25 revealed, Purpose: To ensure that residents at risk for fall events are identified and that appropriate interventions are put in place to minimize their risk for falling and risk for injury . 3.
Residents who score a 10 or higher on the Nursing Advantage Fall Risk Evaluation will be considered a high risk for falls . 8.
Supervision is an intervention and a means of mitigating the risk of an accident.
The facility will provide adequate supervision to prevent accidents.
Adequacy of supervision is based on the individual residents assessed needs and identified hazards in the resident environment.
Adequate supervision may vary from resident to resident and from time to time for the same resident .
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