Cycle 1
Health 2025-01-29 · Fire 2025-01-29
8 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Mount Clemems, MI
Martha T Berry MCF
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
43533 Elizabeth Road, Mount Clemems, MI
(586) 469-5265
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
217
Certified beds
Average residents
210
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1968-04-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.21
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.31
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.93
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.02
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.10
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
5.24
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,345
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.07
Composite VBP score used to determine payment impact.
Payment multiplier
1.0041
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.73
Baseline 20.22% · Performance 20.17% · Measure score 2.73 · Achievement 2.73 · Improvement 0
Healthcare-associated infections
3.31
Baseline 5.74% · Performance 6.84% · Measure score 3.31 · Achievement 3.31 · Improvement 0
Total nurse turnover
5.58
Baseline 41.30% · Performance 40.89% · Measure score 5.58 · Achievement 5.58 · Improvement 0
Adjusted total nurse staffing
8.41
Baseline 5.73 hours · Performance 5.47 hours · Measure score 8.41 · Achievement 8.41 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.58% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 2.35% · Lower 95% interval 6.01% |
| Discharge to community | 29.23% |
50.57%
21.3 pts worse
|
Worse than the National Rate · Eligible stays 41 · Observed rate 17.07% · Lower 95% interval 18.1% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 54.17% |
53.69%
0.5 pts better
|
Numerator 13 · Denominator 24 |
| Discharge mobility score | 29.17% |
50.94%
21.8 pts worse
|
Numerator 7 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 6.06% |
2.29%
3.8 pts worse
|
Numerator 2 · Denominator 33 · Adjusted rate 4.45% |
| Healthcare-associated infections requiring hospitalization | 6.85% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 5.41% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 0.3% |
8.2%
7.9 pts worse
|
Numerator 1 · Denominator 333 |
| Staff flu vaccination coverage | 17.11% |
42%
24.9 pts worse
|
Numerator 58 · Denominator 339 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 8 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
95.0%
4 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
95.0%
2.2 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.1%
2 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.0% · Q3 4.1% · Q4 4.5% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
4.1%
3.2 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.2% · Q3 0.6% · Q4 1.2% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 7.8% |
5.5%
2.3 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 9.5% · Q3 9.7% · Q4 3.9% · 4Q avg 7.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.8% |
19.6%
0.8 pts better
|
19.6%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 17.7% · Q3 18.2% · Q4 18.7% · 4Q avg 18.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.9% |
16.5%
0.6 pts better
|
16.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 15.9% · Q3 14.0% · Q4 18.2% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.1% |
13.9%
4.2 pts worse
|
16.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 25.5% · Q3 16.3% · Q4 15.8% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.2% |
11.7%
0.5 pts worse
|
14.9%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 12.8% · Q3 13.3% · Q4 11.6% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.9% · Q4 1.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
1.7%
2.1 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.5% · Q3 3.6% · Q4 4.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
20.4%
0.1 pts worse
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 25.0% · Q3 21.3% · Q4 16.7% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
5.6%
2.7 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.4% · Q3 2.2% · Q4 2.7% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.1% |
82.8%
2.7 pts worse
|
81.7%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 72.0% · Q2 86.5% · Q3 89.2% · Q4 72.3% · 4Q avg 80.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
11.5%
4.7 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 7.1% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.4% |
1.3%
5.1 pts worse
|
1.6%
4.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.8% |
79.5%
7.3 pts better
|
79.7%
7.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.0% |
24.2%
3.8 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 28.6% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-15 · Fire 2023-11-15
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-08-25 · Fire 2022-08-25
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-29
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-29
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-01-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-29
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-29
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-02-28
F · Potential for more than minimal harm
2023-11-15
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-05-01
F · Potential for more than minimal harm
2022-08-25
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-05-01
F · Potential for more than minimal harm
2022-08-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-01-09
F · Potential for more than minimal harm
2022-08-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-01-20
F · Potential for more than minimal harm
2022-08-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-04
F · Potential for more than minimal harm
2022-08-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-04
E · Potential for more than minimal harm
2022-08-25
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-04-15
E · Potential for more than minimal harm
2022-08-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-08-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-01-09
E · Potential for more than minimal harm
2022-08-25
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-01-09
E · Potential for more than minimal harm
2022-08-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-04
Inspection history
Recent health citations
G · Actual harm
2025-11-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-01-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-29
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-01-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-09-17
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-09-03
D · Potential for more than minimal harm
2023-11-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-05-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-15
F · Potential for more than minimal harm
2022-08-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-04
E · Potential for more than minimal harm
2022-08-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-04
E · Potential for more than minimal harm
2022-08-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-10-04
D · Potential for more than minimal harm
2022-08-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-10-04
Penalties and ownership
What sits behind the stars
Ownership
Beg, Mirza
Operational/Managerial Control · Individual
County Of Macomb
Operational/Managerial Control · Organization
Evans, Kevin
Operational/Managerial Control · Individual
Luyeho, Christine
Operational/Managerial Control · Individual
Thompson, Patrick
Corporate Director · Individual
White Lake Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Lakepointe Senior Care and Rehabilitation Center
Clinton Township, MI
5-star overall rating with 5-star inspections with $34,034 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Mission Point Nursing & Physical Rehabilitation Ce
Clinton Township, MI
2-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Church of Christ Care Center
Clinton Township, MI
2-star overall rating with 2-star inspections with $23,595 in total fines with 9 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Jump out