Inspection Reports for Holland Home Raybrook Campus

The inspection was conducted as a renewal licensing study to assess compliance with applicable rules and regulations for the facility's license renewal.

The facility was found to be in non-compliance with the rule requiring evidence of initial tuberculosis screening for residents prior to admission. Specifically, Resident A's record lacked TB test results prior to admission, establishing a violation.

The document serves as a renewal notification for the Home for the Aged license following an administrative review of licensing activity over the past year.

The facility was found to be in substantial compliance with the public health code and administrative rules regulating home for the aged facilities, resulting in license renewal.

The inspection was conducted in response to a complaint alleging that Resident A was observed with multiple bruises on 9/27/22 and that Resident A’s responsible person was not notified of the bruises.

The investigation found that Resident A had multiple bruises observed on 9/22/22 which were worsening by 9/27/22. The facility failed to complete an incident report and notify Resident A’s responsible person and physician in a timely manner, violating reporting requirements. Resident A was hospitalized on 9/28/22 and later passed away in the skilled nursing area. The violation of reporting incidents was established.

The complaint alleged that Resident A was observed with multiple bruises on 9/27/22 and that Resident A’s responsible person was not notified. The violation was substantiated based on interviews and document review.

The inspection was conducted to document a decrease in licensed bed capacity due to renovations in the memory care units and to complete the original licensing study for the facility.

The facility completed renovations on multiple floors creating updated memory care units with new resident rooms and common areas. The building was approved for resident occupancy and received full fire safety approval.

The purpose of the visit was to define the licensed areas of the home for the aged (HFA) and document the home’s organized program of resident safety, supervision, and protection as part of the original licensing study.

The report describes the licensed areas of the facility, including the Devos and Cook Wings, and notes the removal of certain unlicensed areas from the licensed HFA space. The home has an organized program for resident safety, supervision, and protection, including secured entrances, video monitoring, staff training, and visitor signage. The licensed day/dining space exceeds the required square footage for the licensed capacity.

The facility proposed adding 17 beds to their Home for the Aged license, specifically for residents requiring additional services due to memory loss, prompting an inspection of the addition.

The inspection found the addition compliant with all applicable rules and statutes, including handicap accessibility and secure unit requirements. The facility was recommended to increase its licensed capacity from 248 to 265 beds.