Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Martha T Berry Mcf during CMS and state inspections, most recent first.
Homelike Environment and Hot Water Temperature Deficiencies: A resident with intact cognition reported damaged room conditions, including holes in the bed footboard and wall, and facility leaders acknowledged the areas needed repair. In addition, multiple resident bathrooms had hot water temperatures below the facility policy range of 105 to 115 degrees, and a family member and a resident reported the shower water often ran cold.
A resident with dementia and type 2 DM was not invited to or included in care conferences for care planning, and the EMR had no documentation of an invitation, attendance, refusal, or reason for absence. The resident stated they had never attended a care conference and wanted to participate, while the SW said the resident was excluded due to behavioral concerns about family but admitted this was not documented. The DON stated the resident and responsible party should be invited, and the facility policy required resident input and documentation if the resident could not participate.
The facility failed to provide timely repositioning and transfer assistance for two dependent residents. One resident with paralysis, malnutrition, and dementia was repeatedly observed slumped and poorly positioned in a Broda chair and later remained in bed with a wedge on the floor, while staff only encouraged repositioning. Another resident with a chronic heel ulcer, malnutrition, and dementia remained in bed past the planned time to be up for family visits and lunch, despite being dependent on staff for all care and transfers.
Failure to apply ordered heel boots: A resident with peripheral vascular disease, bilateral knee contractures, type 2 DM, and a history of diabetic foot ulcers had an order for protective boots while in bed, and the care plan included heel protectors or floating the heels. Staff observed the resident in bed multiple times without the boots in place, and the TARs did not show documented refusals. An LPN said the resident should have had the boots on, while the DON stated ordered heel boots should be applied and refusals documented in the TAR.
A resident with severe cognitive impairment and high fall risk was left unsupervised in a hallway after being instructed by an activity aide to hold onto a handrail while the aide returned a tray table to the resident's room. The resident, who was not using their prescribed walker, walked away from the handrail and fell, sustaining multiple serious injuries. Staff interviews and record review confirmed that the resident required close supervision and assistive devices, but these interventions were not implemented at the time of the incident.
A facility failed to update the PASARR for a resident with mental illness diagnoses, including paranoid schizophrenia and PTSD, after a hospital exemption. The resident's Level II screening was not completed within 30 days as required. Staff interviews revealed a lack of awareness and responsibility for completing necessary forms, contrary to facility policy.
A resident with moderately impaired cognition and dental issues did not have a comprehensive dental care plan implemented. Despite the resident's expressed desire for dental care at a dentist's office, the facility failed to document a care plan with interventions. Social Worker A confirmed the absence of a care plan, and the DON emphasized the expectation for timely and accurate care plans. A request for the care plan policy was not fulfilled by the survey's end.
A resident with a history of acute respiratory failure and impaired mobility was found with untreated and improperly documented skin conditions. Observations revealed undated and uninitialed bandages, and uncovered wounds, contrary to the facility's protocol. The resident's care plan included specific wound care orders that were not documented as completed, highlighting a failure in implementing and documenting skin interventions.
A resident with reduced mobility and cognitive impairment developed a stage 3 pressure ulcer due to the facility's failure to implement necessary interventions. Despite being at risk, no specific measures were taken to prevent pressure ulcers, leading to the progression of a deep tissue injury. The facility did not follow its own policy on pressure injury prevention, as confirmed by staff interviews.
A resident with dementia and severe cognitive impairment experienced multiple falls due to inadequate supervision and ineffective fall interventions. Despite having a care plan with specific interventions, these were not consistently implemented, leading to falls and a hospitalization for a hip fracture. Facility staff acknowledged the lapses in implementing and assessing the effectiveness of these interventions.
A resident with chronic pain and COPD did not receive a prescribed Lidocaine Patch for pain management on multiple occasions. The facility's MAR indicated a code requiring documentation for non-administration, but no explanation was provided. Despite having the medication available, the facility failed to adhere to its policy for timely medication administration, resulting in a deficiency.
A medication error occurred when an LPN crushed and administered extended-release and enteric-coated medications to a cognitively impaired resident without consulting the pharmacy, resulting in a 7.4% error rate. The medications, Diltiazem ER and Methenamine Hippurate, should not have been crushed, as confirmed by the Unit Manager and a pharmacist.
A resident with severe cognitive impairment had their debit card misappropriated by an employee, who used it without permission. The incident was discovered when the resident's family noticed unauthorized charges and reported it to the facility. An investigation confirmed the employee's actions through video footage, leading to the employee's confession and termination.
Homelike Environment and Hot Water Temperature Deficiencies
Penalty
Summary
The facility failed to provide a homelike environment for nine residents by allowing room and bathroom conditions that were not in good repair and by not maintaining warm/hot water temperatures in resident bathrooms. One resident, who had hypertension and an anxiety disorder and scored 15/15 on the Brief Interview of Mental Status, pointed out holes in the footboard of the bed and a large hole in the wall behind the bed and stated that the holes bothered them and they wished it was fixed. During a room tour, the Housekeeping Director acknowledged the areas were in need of repair, and the Maintenance Director later confirmed the areas were in need of repair and that all rooms should be in good repair and comfortable for residents. The hot water concern involved multiple resident rooms. A family member reported that one resident said the shower room water often ran cold. When hot water temperatures were measured in several bathrooms after the water had run for 3 minutes, the readings were 80 degrees Fahrenheit, 99 degrees Fahrenheit, 77 degrees Fahrenheit, and 86 degrees Fahrenheit in the affected rooms. One resident stated, "It's cold!" and said the water starts out warm but is cold by the end of the shower. The facility's hot water temperature logs showed the affected rooms had last been measured several weeks earlier, and the facility policy stated water temperatures are maintained between 105 and 115 degrees.
Failure to Invite Resident to Care Conferences
Penalty
Summary
The facility failed to ensure that a resident was invited to and included in care conferences for care planning. R103 was interviewed on 3/31/26 and stated they wanted to get out of the facility, had never attended a care conference meeting, did not know anything about them, and wanted to attend their care conferences. Record review showed care conferences were held for R103 on 11/5/25 and 2/11/26, but there was no documentation of the resident being invited, attending, refusing, or any reason for not attending either conference. R103 was admitted with diagnoses including dementia and type 2 diabetes, and the most recent quarterly MDS showed moderately impaired cognition and that the resident required setup and cleanup help with oral hygiene and eating. On 4/2/26, the SW stated the resident had not been invited or included in the care conferences because of concerns about behavioral issues toward family, but acknowledged this was not documented in the record and that the resident should have been included in the care planning process. The DON stated the resident and responsible party should be invited to care conferences, which are usually conducted by the SW. The facility policy stated the comprehensive care plan should include resident input, the IDT should discuss the plan with the resident at regularly scheduled conferences, and if the resident is unable to participate, an explanation should be documented in the medical record.
Failure to Reposition and Transfer Two Dependent Residents
Penalty
Summary
The facility failed to provide timely repositioning and transfer assistance for two dependent residents, R85 and R160. R85, who had diagnoses including right-sided paralysis, malnutrition, and dementia, was repeatedly observed slumped and leaning to the left in a Broda wheelchair, with the left shoulder lower toward the armrest, the head on the left bolster, and the left elbow and arm positioned outside the back of the chair. R85 was also observed in bed on the left side with a foam wedge on the floor beside the bed, and later remained in the wheelchair with the arm through the opening at the back of the chair while staff only encouraged position change and did not reposition the resident. The care plan documented poor trunk control, need for staff to anticipate care needs, and the MDS showed severely impaired cognition and dependence for transfers, dressing, eating, toileting, hygiene, and bed mobility. R160, who had diagnoses including a chronic left heel ulcer, malnutrition, and dementia, was observed remaining in bed for extended periods despite a care plan stating the resident was to be out of bed and ready for visits around 11 AM. On one observation, R160 remained in bed through late morning and was not dressed and seated in the wheelchair for family visitation until 12:17 PM, after the planned time. On another day, R160 was still in bed at midday with a family member present and had not been up in the wheelchair and ready for lunch. The MDS documented severely impaired cognition and dependence on staff for rolling, dressing, toileting, hygiene, transfers, and ambulation, and a CNA reported that R160 required total care and was not likely to initiate activity.
Failure to Apply Ordered Heel Boots
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to apply protective heel boots for a resident with an order for boots while in bed. The resident was admitted with peripheral vascular disease, bilateral knee contractures, chronic pain syndrome, and type 2 diabetes, and the MDS indicated a BIMS score of 15 out of 15 with the resident at risk for developing pressure ulcers/injuries. The care plan identified the resident as at risk for impaired skin integrity related to impaired mobility, contractures, medication use, incontinence, weakness, and recurring diabetic ulcers to the feet, and included heel protector boots on bilateral feet and/or floating the heels with a pillow while in bed. Observations on multiple occasions showed the resident lying in bed without the protective heel boots in place, and a pair of heel boots was seen sitting on a wheelchair outside the resident's room. When asked about refusal, the resident's response was not understandable. An LPN stated they were not aware of the resident refusing the boots and believed the resident would probably agree if asked, and after reviewing the EMR stated the resident should have the boots on. The DON stated that when there is an order for protective heel boots, they should be applied, and if a resident refuses, that refusal should be documented in the TAR. Review of the March and April 2026 TARs did not reveal documented refusals for protective heel boot applications.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate interventions to prevent a fall with injury for a resident with severe cognitive impairment and high fall risk. The resident, who had diagnoses including dementia with psychotic disturbance, syncope, difficulty walking, and a history of falls, was observed ambulating in the hallway using a bedside tray table instead of their prescribed walker. An activity aide intercepted the resident, instructed them to hold onto the handrail, and left to return the tray table to the resident's room, leaving the resident unsupervised. While the aide was away, the resident walked away from the handrail, fell, and sustained significant injuries, including facial fractures, a left radius fracture, and contusions. The resident was found lying face down in a pool of blood and was subsequently transported to the hospital for treatment, where they required intensive care and pain management. The resident's care plan had identified them as a high fall risk, requiring supervision and the use of an assistive device (walker) for ambulation, and staff were aware of the resident's tendency to walk without their device and need for frequent redirection. Interviews with facility staff confirmed that the aide did not remain with the resident or provide hands-on assistance, despite the resident's known cognitive impairment and poor safety awareness. Facility policy required adequate supervision based on individual assessed needs, particularly for residents at high risk for falls. The failure to provide direct supervision and ensure the resident used their prescribed assistive device directly contributed to the fall and resulting injuries.
Failure to Update PASARR for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure an update for a preadmission screening and resident review (PASARR) for a Level II evaluation was completed for a resident with mental illness diagnoses. The resident, identified as R187, was admitted to the facility with diagnoses of paranoid schizophrenia, post-traumatic stress disorder, and dissociative identity disorder. Despite having a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, the resident's PASARR was not updated following a hospital exemption dated 9/18/24. The facility did not complete the necessary Level II screening within 30 days of admission, as required for residents with mental illness diagnoses. Interviews with facility staff revealed a lack of awareness and responsibility regarding the completion of the necessary PASARR forms. Social Worker A was unaware of who was responsible for completing the 3877/3878 forms, and the Director of Nursing (DON) stated that the expectation was for PASARRs and Level II screenings to be completed accurately and timely according to policy. The facility's policy requires that individuals admitted under a Hospital Exempted Discharge and remaining in the facility longer than 30 days must be screened using the State's Level I screening process and referred for a Level II PASARR evaluation if they have or may have mental disorders or intellectual disabilities.
Failure to Implement Dental Care Plan for Resident
Penalty
Summary
The facility failed to implement a dental care plan for a resident, identified as R110, who was observed on January 27, 2025, expressing a desire to have their teeth pulled at a dentist's office rather than at the facility. R110 was admitted with diagnoses including Dysphagia, Malnutrition, Adult Personality Disorders, and Adjustment Disorder, and had a BIMS score indicating moderately impaired cognition. A review of R110's medical record revealed dental consultations and issues with their teeth, but no comprehensive dental care plan with interventions was noted. On January 29, 2025, Social Worker A confirmed the absence of a care plan for R110 after initially needing to consult another social worker. The Director of Nursing stated that care plans are expected to be completed accurately and timely for each resident. A request for the care plan policy was made but not received by the end of the survey.
Failure to Implement and Document Skin Care Interventions
Penalty
Summary
The facility failed to implement proper skin interventions and document skin care treatments for a resident, identified as R153, who was observed with multiple untreated and improperly documented skin conditions. On two separate occasions, R153 was found with undated and uninitialed bandages on their right elbow and right upper thigh, and a discolored area on the right leg that was not covered. Additionally, a large red area with a blister on the left leg was observed uncovered, and R153 reported that the bandage on their right elbow had fallen off and needed replacement. The Unit Manager and Wound Nurse confirmed that the facility's protocol requires bandages to be dated and initialed, which was not adhered to in this case. A review of R153's medical records revealed physician's orders for specific wound care treatments that were not documented as completed on the Treatment Administration Record (TAR) for a specified date. R153 was admitted with a diagnosis of Acute Respiratory Failure and had a care plan indicating a risk for impaired skin integrity due to impaired mobility. The care plan included goals and interventions for skin assessment and monitoring, which were not effectively implemented. The Director of Nursing confirmed that treatments should be dated and initialed, as per the facility's policy on wound care and treatment standard operating procedures.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development of a deep tissue injury (DTI) and subsequent stage 3 pressure ulcer in a resident. The resident, who was admitted with diagnoses including Dementia, Muscle Weakness, and Psychotic Disorder, was significantly cognitively impaired and dependent on staff for bed mobility. After sustaining a fall resulting in a left hip fracture, the resident's mobility was further reduced, increasing their risk for pressure ulcers. Despite this, no new interventions were put in place to address the resident's increased risk, as indicated by their Braden Score of 16, which classified them as 'at risk' for pressure ulcers. Observations and medical records revealed that the resident was found with their heels flat on the bed, and later developed discoloration and a DTI on the left heel, which progressed to a stage 3 pressure ulcer. The facility's policy on pressure injury prevention and management was not followed, as evidenced by the lack of specific interventions tailored to the resident's risk factors and condition. The resident's care plan did not include measures such as offloading heels or repositioning, which are standard practices for pressure ulcer prevention. Interviews with the Wound Care Nurse, Director of Nursing, and Assistant Director of Nursing confirmed that no interventions were implemented prior to the discovery of the DTI, aside from the use of a specialty mattress. The facility's failure to adhere to its own policy and implement evidence-based interventions for pressure ulcer prevention contributed to the development of the resident's pressure ulcer.
Inadequate Supervision and Fall Interventions Lead to Resident Falls
Penalty
Summary
The facility failed to provide adequate supervision and effective fall interventions for a resident, resulting in multiple falls and a hospitalization. The resident, who was admitted with diagnoses including dementia, hypertension, and muscle weakness, was severely cognitively impaired and dependent on staff for all activities of daily living. Despite these conditions, the resident experienced several unwitnessed falls over a period of months, including incidents where they were found kneeling next to the bed, sitting slouched against a wall, and on the floor pulling on their feeding tube. The resident's care plan included various interventions to mitigate fall risks, such as frequent rounding for safety, reminders not to get up unassisted, and the use of non-skid socks and floor mats. However, these interventions were not consistently implemented or effective. For instance, after a fall on September 25, 2024, it was noted that the resident did not have a dycem in their wheelchair as care planned, and no additional fall interventions were put in place. Following a fall on October 31, 2024, which resulted in a hip fracture and hospitalization, no new interventions were implemented upon the resident's return. Interviews with facility staff, including the Risk Investigation Manager and the Director of Nursing, revealed acknowledgment of the lapses in implementing and assessing the effectiveness of fall interventions. The facility's protocol required comprehensive care plans addressing identified risk factors and adequate supervision to prevent accidents, but these measures were not adequately followed, contributing to the resident's repeated falls and subsequent injury.
Failure to Administer Pain Patch as Prescribed
Penalty
Summary
The facility failed to administer a prescribed pain management medication, a Lidocaine Patch, to a resident with chronic pain and Chronic Obstructive Pulmonary Disease (COPD). The resident reported that the pain patch was not administered on multiple occasions, including specific instances on December 20th and January 24th, as noted in the Medication Administration Record (MAR). The MAR indicated a code '9', which required a corresponding nursing note to explain the reason for non-administration, but no such documentation was found. The facility had the medication available in their storage, indicating that the failure was not due to a lack of supply. The resident's care plan highlighted the need for effective pain management, with interventions to monitor pain levels and confer with a physician if necessary. Despite this, the facility did not adhere to its policy for ensuring the availability and timely administration of medications. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the Lidocaine Patch was available on-site and that documentation should accompany any non-administration of medication. The facility's policy outlined procedures for acquiring and administering medications, which were not followed in this instance, leading to a deficiency in providing appropriate pain management for the resident.
Medication Error Due to Improper Crushing of Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 7.4% error rate during a medication pass observation. A Licensed Practical Nurse (LPN) administered medications to a resident with significant cognitive impairment, including Diltiazem ER and Methenamine Hippurate, by crushing them and mixing them with pudding. The LPN was unsure if these medications could be crushed and referenced a medication book, which did not provide the necessary information. Despite the uncertainty, the LPN proceeded to crush the medications without consulting the pharmacy for clarification. The resident involved had a medical history of unspecified dementia, arthritis, and bladder disorders, and was on medication for high blood pressure and urinary tract infection prevention. The Unit Manager and a pharmacist later confirmed that the medications should not have been crushed, as this could lead to adverse effects such as a sudden drop in blood pressure and reduced effectiveness of the antimicrobial medication. The facility's policy required that medications be crushed according to physician orders and that the pharmacist review medications for safety and stability, which was not adhered to in this instance.
Misappropriation of Resident's Debit Card by Employee
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property, specifically a debit card, by an employee. The incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview of Mental Status (BIMS) score of 6, who was unable to recall the event. The resident's debit card was used without permission by an employee, who later confessed to the unauthorized use. The facility's investigation confirmed the misuse of the card, which was substantiated by video footage showing the employee's actions. The resident's family member had provided the resident with a purse containing the debit card to help them feel independent. The family became aware of the unauthorized charges and reported the incident to both the police and the facility. The facility conducted an investigation, which included reviewing video footage and interviewing the employee, who admitted to the crime. The employee was subsequently terminated, and the resident's responsible party was reimbursed for the unauthorized charges.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mount Clemems
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakepointe Senior Care And Rehabilitation Center | 3 mi | — | 0 | 0 |
| Harmony Village Of Clinton | 3.9 mi | — | 1 | 0 |
| Church Of Christ Care Center | 4.3 mi | — | 1 | 0 |
| Michigan Veterans Home Of Chesterfield Township | 4.3 mi | — | 1 | 0 |
| Medilodge Of Shoreline | 4.4 mi | — | 7 | 0 |
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