Inspection Reports for
Holland Home Raybrook Campus
2121 Raybrook St SE, Grand Rapids, MI 49546, United States, MI, 49546
Back to Facility Profile4 Reports
Inspection Report — Dec 18, 2023
Renewal
Date: Dec 18, 2023
Visit Reason
Renewal inspection of the adult foster care family home license.
Findings
The facility was found to be in non-compliance with 1 rule; a written corrective action plan was required before the license is renewed.
Deficiencies (1)
R 325.1922 Admission and retention of residents: Resident A did not have tuberculosis test results on file prior to admission, so it is unknown whether the required TB testing was completed.
Report Facts
Corrective action plan due: 15
Inspection Report — Oct 15, 2018
Date: Oct 15, 2018
Visit Reason
Addendum purpose: Decrease licensed bed capacity to accommodate renovated memory care units.
Findings
The facility's licensed capacity was reduced to 236 following renovations to memory care units on multiple floors.
Report Facts
Inspection Report — Dec 2, 2010
Date: Dec 2, 2010
Visit Reason
Addendum to Original Licensing Study to define licensed areas and document resident safety, supervision, and protection program; no change in licensed bed capacity.
Findings
The home has an organized program to provide for the safety, supervision, and protection of its residents. The change in room function on the first floor corridors does not constitute a major building modification.
Report Facts
Day/dining room space: 10455
Required day/dining room space: 7950
Inspection Report — May 9, 2005
Date: May 9, 2005
Visit Reason
Increase capacity from 248 to 265 beds for the Home for the Aged license.
Findings
The facility is in compliance with all applicable rules and statutes. The proposed 17 additional beds were inspected and approved.
Report Facts
6 CMS Surveys
Inspection Report — Dec 23, 2025
Complaint Investigation
Date: Dec 23, 2025
Visit Reason
Investigation of a complaint received on 2025-12-23 about verbal abuse and medication storage errors.
Complaint Details
Verbal abuse of Resident #105 by RN K: established. Medication storage and administration errors involving Resident #103: established.
Findings
Two violations were established: verbal abuse of Resident #105 by RN K and improper medication storage and administration practices involving Resident #103.
Deficiencies (2)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: RN K verbally abused Resident #105 by stating 'I'm going to kick your a**' and similar threats, which was substantiated by eyewitness accounts.
F 0761 Ensure drugs and biologicals used in the facility are labeled and stored properly: LPN C failed to properly store and discard medications for Resident #103, increasing the risk of medication errors and potential harm.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN K | Registered Nurse | Named in the verbal abuse finding towards Resident #105. |
| LPN C | Licensed Practical Nurse | Named in the medication storage and administration finding involving Resident #103. |
Inspection Report — Feb 5, 2025
Monitoring
Date: Feb 5, 2025
Visit Reason
Interim inspection to determine compliance.
Findings
Multiple deficiencies were found including failure to maintain dignity and timely response to call lights, failure to protect resident privacy, failure to resolve resident grievances, failure to timely report neglect, failure to revise care plans, failure to prevent falls and ensure safe wheelchair transport, failure to provide special eating utensils, failure to maintain sanitary food storage and labeling, and failure to implement infection prevention and control measures.
Deficiencies (9)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: Resident #76 experienced delayed call light response times up to 62 minutes, causing frustration and potential decline in quality of life.
F 0583 Keep residents' personal and medical records private and confidential: Resident #50's privacy was breached when staff entered her room without knocking and a laptop displaying protected health information was left unattended in a hallway for 6 minutes.
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances: Resident #34's concerns about being left wet and soiled for hours were not adequately investigated or resolved, and documentation was lacking.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: Resident #34's allegations of neglect were not reported to the State Agency in a timely manner and no investigation was completed.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: Resident #60's care plan was not updated to reflect a recent right humerus fracture and related restrictions, risking further injury and pain.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: Resident #8 fell resulting in fractures; bedside table with wheels was used as a support; Residents #27 and #42 were transported in wheelchairs without foot pedals in place, risking falls.
F 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance: Residents #55 and #30 were not provided with their prescribed adaptive eating utensils during meals, impairing their ability to eat independently.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: Dry storage area had leaking containers; resident refrigerators contained unlabeled and uncovered food items, risking foodborne illness.
F 0880 Provide and implement an infection prevention and control program: Staff failed to consistently use personal protective equipment and perform proper hand hygiene when caring for residents on transmission-based contact precautions, risking spread of infectious diseases.
Inspection Report — Jan 26, 2024
Complaint Investigation
Date: Jan 26, 2024
Visit Reason
Investigation of a complaint received on 2023-12-24 about verbal, physical, and psychosocial abuse of Resident #80 by staff.
Complaint Details
Verbal, physical, and psychosocial abuse of Resident #80 by CNA M: established.
Findings
The allegation of mental and verbal abuse was substantiated. Certified Nursing Assistant (CNA) M was observed yelling at Resident #80 and grabbing her scarf, causing bruises. CNA M was discharged from employment for verbal abuse and being disruptive in a resident care area.
Deficiencies (1)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: CNA M yelled at Resident #80 in a disrespectful and intimidating manner, grabbed and flipped her scarf, and caused bruises on the resident's arms.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nursing Assistant | Named in the verbal and physical abuse findings involving Resident #80. |
Inspection Report — Jan 26, 2024
Complaint Investigation
Date: Jan 26, 2024
Visit Reason
Investigation of a complaint received on 2023-12-24 about verbal, physical, and psychosocial abuse by staff.
Complaint Details
Verbal and physical abuse of Resident #80 by CNA M: established. Failure to complete Level II PASARR for Resident #63: established. Failure to sign out narcotic medications for Residents #9 and #5: established. Failure to complete annual nurse competencies for LPN J, LPN HH, and LPN O: established. Medication labeling and storage deficiencies: established. Failure to offer pneumococcal vaccine PCV15 or PCV20 to Residents #38, #47, and #57: established.
Findings
The facility failed to protect Resident #80 from verbal, physical, and psychosocial abuse by CNA M, resulting in substantiated abuse with physical injuries and staff discharge.
Deficiencies (6)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: CNA M yelled at Resident #80 in a disrespectful tone, grabbed and pulled the resident's scarf tightly under her chin, causing bruises on both arms; CNA M was discharged for verbal abuse and being disruptive in a resident care area.
F 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed: The facility failed to ensure a Level II PASARR evaluation was completed for Resident #63 who remained in the facility longer than 30 days, resulting in potential unmet mental health and psychiatric care needs.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: Nurses failed to sign out narcotic medications on the narcotic count sheet after dispensing and administering oxycodone and methadone to Residents #9 and #5, resulting in inaccurate documentation and potential medication mismanagement.
F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: Three licensed nurses (LPN J, LPN HH, LPN O) did not complete annual competency evaluations for January 2024, placing residents at risk due to unverified nursing competencies.
F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: Medication carts contained unlabeled eye drops, inhalers, insulin pens, and expired or undated medications, risking decreased efficacy and potential harm.
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: The facility failed to track and offer the pneumococcal vaccine PCV15 or PCV20 to Residents #38, #47, and #57, resulting in delayed opportunity to receive or decline the vaccination.
Inspection Report — Nov 29, 2023
Complaint Investigation
Date: Nov 29, 2023
Visit Reason
Investigation of complaints received on multiple dates regarding resident-to-resident physical altercations, falls with head injury, and inadequate supervision and care.
Complaint Details
Resident-to-resident physical altercations: Residents #101, #102, #103, and #104 involved in incidents with slapping and biting; investigations incomplete and interventions insufficient. Falls with head injury: Resident #106 fell and lost consciousness with delayed hospital transfer; Residents #108 and #101 had inadequate neurological monitoring post-fall.
Findings
The facility failed to thoroughly investigate allegations of abuse and failed to provide adequate supervision and interventions to prevent resident-to-resident physical altercations in 4 residents. The facility also failed to adequately assess, notify medical providers, and perform neurological checks after falls with head injury for 3 residents, resulting in inadequate monitoring and potential for untreated injury.
Deficiencies (2)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: The facility failed to provide adequate supervision and implement interventions to prevent resident to resident physical altercations in Residents #101, #102, #103, and #104, resulting in potential for physical injury and psychosocial harm.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: The facility failed to adequately assess and notify the medical provider of a fall with head injury in a timely manner for Resident #106 and failed to perform adequate monitoring and neurological checks after falls for Residents #106, #108, and #101, resulting in inadequate monitoring and potential for unnoticed and untreated physical injury.
Inspection Report — Jan 11, 2023
Complaint Investigation
Date: Jan 11, 2023
Visit Reason
Investigation of a complaint received on 2023-01-11 about staff response to exit door alarms, food safety, and refrigerator maintenance.
Complaint Details
Staff response to exit door alarms: violation established. Food safety including date marking and cleaning: violation established. Personal refrigerator temperature log maintenance for Resident #48: violation established.
Findings
Three deficiencies were cited: failure to develop a policy and properly respond to exit door alarms risking resident safety; failure to properly date mark potentially hazardous foods and clean food contact surfaces increasing risk of foodborne illness; failure to maintain personal refrigerator temperature logs resulting in unknown discard dates and potential food contamination.
Deficiencies (3)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to develop a policy and procedure for staff response to exit door alarms and did not properly respond to a door alarm, risking residents exiting unsupervised.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to properly date mark potentially hazardous foods and clean food and non-food contact surfaces, increasing risk of foodborne illness.
F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors: the facility failed to follow their policy regarding maintenance of personal refrigerator temperature logs for Resident #48, resulting in missed checks and potential food contamination.
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