Martha T Berry Mcf
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
falls at the facility. The DON reported recent education was provided for activity aide (AA C). AA C had intercepted a resident (Resident R901) walking down the hallway holding onto a bedside table. AA C took the tray table from Resident R901 and instructed Resident R901 to grab the handrail and to stay there. When AA C turned away to return the tray table to the resident's room, Resident 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 Resident R901 for around two years. AA C recounted the incident with Resident R901 and reported they had been on their way to dietary when they observed Resident R901 coming up the hall to the nurse's station pushing a bedside tray table. AA C met up with Resident R901 in the hallway around twenty feet or so from the resident's room. AA C felt Resident R901 was in danger while using the bedside table and instructed Resident 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 Resident R901's room to find that Resident 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 Resident R901's fall and reported Resident 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 Resident R901 stand at the railing and holding on. AA C then went to Resident R901's room and as AA C walked away, Resident 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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Martha T Berry MCF in Mount Clemems, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Mount Clemems, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Martha T Berry MCF or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.