Martha T Berry MCF

In the surveyor’s words

From the most serious findings on record at Martha T Berry MCF, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 10, 2025

  Based on interview and record review the facility failed to ensure appropriate interventions were implemented to prevent a fall with injury for one resident (R901) of three reviewed for falls. Findings include:This citation pertains to Intake 2661503.A review of a progress note by Licensed Practical Nurse (LPN) A dated 10/05/25 at 12:38 PM, documented, Resident was observed lying in the hallway face down in a pile of blood. Writer (LPN A) assisted resident to (their) back then into wheelchair. Writer applied pressure to laceration on (right) R side of forehead and to bridge of nose . Writer asked resident what happened, and (they) began to cry stating that (their) head hurts. Writer applied pressure to bleeding areas until the ambulance arrived. […]

• Actual harm, isolatedF600May 12, 2021

  This citation pertains to intake: MI 217. Based on observation, interview, and record review, the facility failed to prevent physical abuse from a staff person, for one sampled Resident 45 (R45) of four sampled residents reviewed for abuse, resulting in physical abuse and psychosocial distress using the reasonable person concept. Findings include: On 5/10/21 at 10:12 AM, R45 was observed in their room pulling sheets on a bed that was already made. An attempt to interview R45 was made, but not successful due to R45's impaired cognition. On 5/11/21 at 8:30 AM, R45 was observed in their bed under a blanket and was asked how they were doing and stated, I'm going crazy. […]

• No harm, potential for more than minimal, widespreadF880Aug 25, 2022

  Based on observation, interview, and record review, the facility failed to 1.) ensure signage for identifying isolation room/personal protective equipment (PPE) was placed for three (3) Residents (R5, R168, and R174), of three residents reviewed for COVID-19 isolation rooms and 2.) appropriate PPE use in the facility, resulting in the potential of spreading a communicable respiratory disease in a vulnerable population of 184 residents. Findings include: During an observation on 8/22/2022 at 11:00 AM, upon entering the facility's main lobby, writing on a white board alerted those entering the facility that, 3 Residents COVID-19 Positive. During the entrance conference, Nursing Home Administrator (NHA) A confirmed positive cases of COVID-19 in the facility. […]

• No harm, potential for more than minimal, widespreadF812May 12, 2021

  Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen, resulting in the increased potential for cross contamination and foodborne illnesses. This deficient practice had the potential to affect all residents that consume food from the kitchen. Findings include: On 5/10/21, during an initial tour of the kitchen with Executive Chef Z from 8:30 AM-9:30 AM, the following items were observed: In the walk-in cooler, there was an opened bag of cut lettuce dated 5/3-5/5, and an opened, undated container of sour cream. […]

• No harm, potential for more than minimal, patternF584Apr 2, 2026

  Based on observation, interview, and record review, the facility failed to provide a homelike environment including the availability of warm/hot water, for nine residents (R36, R81, R82, R85, R87, R89, R123, R136, and R160). Findings include:R36 On 3/31/26 at 9:45 AM, R36 was observed lying in bed watching television. R36 pointed to the foot of the bed and stated, Those holes bother me. I don't like that and I wish it was fixed. The footboard at the end of the bed was noted to have two large open areas where the laminate on the footboard was missing and loose. Further observation revealed, in the wall behind the bed was a large hole about 6 inches long and 3 inches wide. […]