Inspection Reports for
Holland Home Raybrook Campus
2121 Raybrook St SE, Grand Rapids, MI 49546, United States, MI, 49546
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 23, 2025
Visit Reason
The inspection was conducted to investigate substantiated allegations of verbal abuse by a staff member towards a resident and to review medication storage and administration practices following a suspected medication error incident.
Complaint Details
The complaint investigation substantiated verbal abuse by RN K towards Resident #105, confirmed by four eyewitnesses. The investigation into medication storage revealed a potential medication error involving Resident #103, who was hospitalized after becoming unresponsive. The facility could not confirm if the wrong medication was administered.
Findings
The facility substantiated verbal abuse by a registered nurse towards Resident #105, involving inappropriate threatening language. Additionally, the facility failed to properly store and dispose of medications for Resident #103, resulting in a potential medication error and the resident becoming unresponsive and hospitalized.
Deficiencies (2)
F 0600: The facility failed to protect Resident #105 from verbal abuse by a staff member who threatened to physically harm the resident. The abuse was substantiated by multiple eyewitness accounts.
F 0761: The facility failed to properly store and dispose of medications for Resident #103, leading to a potential medication error and the resident becoming unresponsive and requiring hospitalization.
Report Facts
Residents reviewed for abuse: 4
Residents reviewed for medication storage: 7
Date of incident: Dec 13, 2025
Date of verbal abuse incident: Nov 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN K | Registered Nurse | Named in verbal abuse finding towards Resident #105 |
| CNA F | Certified Nursing Assistant | Eyewitness and reporter of verbal abuse by RN K |
| CNA W | Certified Nursing Assistant | Eyewitness and reporter of verbal abuse by RN K |
| LPN P | Licensed Practical Nurse | Reported on Resident #105's wandering and verbal abuse investigation |
| NHA A | Nursing Home Administrator | Conducted investigation and substantiated verbal abuse by RN K |
| LPN C | Licensed Practical Nurse | Involved in medication administration and potential medication error for Resident #103 |
| NM I | Nurse Manager | Reported and investigated potential medication error involving Resident #103 |
| DON B | Director of Nursing | Reported awareness of potential medication error and confirmed policy violations |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Feb 5, 2025
Visit Reason
The inspection was conducted to investigate multiple complaints related to resident dignity, privacy, grievance resolution, neglect reporting, care planning, fall prevention, adaptive equipment provision, food safety, and infection control practices.
Complaint Details
The investigation was complaint-driven, focusing on issues including call light response delays, privacy breaches, unresolved grievances, neglect reporting failures, inadequate care planning, fall hazards, lack of adaptive equipment, food safety violations, and infection control lapses. Substantiation status is not explicitly stated.
Findings
The facility was found deficient in timely response to resident call lights, protecting resident privacy, resolving grievances, reporting neglect, updating care plans, preventing falls, providing adaptive eating utensils, maintaining food safety and sanitation, and implementing infection prevention and control measures including proper use of PPE during transmission-based precautions.
Deficiencies (9)
F 0550: The facility failed to maintain dignity and respond to a resident's call light in a timely manner, with response times up to 62 minutes, causing frustration and potential decline in quality of life.
F 0583: The facility failed to protect resident privacy when staff entered a resident's room without knocking and left electronic medical records open and unattended in a common area.
F 0585: The facility failed to resolve a resident's voiced concerns about care, including being left wet and soiled for hours, resulting in frustration and potential psychosocial decline.
F 0609: The facility failed to timely report allegations of neglect to the State Agency for a resident left wet and soiled for hours, risking undetected neglect.
F 0657: The facility failed to revise a resident's care plan to reflect a recent right humerus fracture and related restrictions, risking further injury and pain.
F 0689: The facility failed to implement interventions and provide adequate supervision to prevent a fall for one resident and failed to safely transport two residents in wheelchairs without foot pedals, resulting in a fall with fracture and potential fall risks.
F 0810: The facility failed to provide special eating utensils as ordered during meal times for two residents, impairing their ability to eat independently and risking weight loss.
F 0812: The facility failed to maintain sanitary conditions in the dry storage area and ensure proper labeling and dating of foods in resident refrigerators, risking foodborne illness.
F 0880: The facility failed to implement infection prevention and control measures by not ensuring staff used appropriate personal protective equipment and hand hygiene in rooms under transmission-based precautions, risking cross contamination and spread of infectious diseases.
Report Facts
Call light response times: 62
Number of times Resident #34 left soiled: 50
Distance wheelchair pushed: 75
Distance wheelchair pushed: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Reported failure to timely report neglect and unresolved grievance follow-up |
| DON B | Director of Nursing | Provided expectations on call light response times and PPE use |
| RN-MDS MM | Registered Nurse | Responded to Resident #8 fall and provided interview on incident |
| UM GG | Unit Manager | Responsible for following up on Resident #34's concerns but failed to document or investigate |
| CNA AAA | Certified Nursing Assistant | Received disciplinary action related to Resident #34's care concerns |
| IP N | Infection Preventionist | Reported PPE and hand hygiene expectations during transmission-based precautions |
| RN II | Registered Nurse | Reported wheelchair safety expectations for Resident #27 |
| UM T | Unit Manager | Reported wheelchair safety expectations and PPE signage issues |
| Dietitian EEE | Dietitian | Reported use of disposable utensils due to illness outbreak and lack of special utensils provision |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 26, 2024
Visit Reason
The investigation was conducted due to an allegation of verbal, physical, and psychosocial abuse by a Certified Nursing Assistant (CNA M) toward Resident #80 on 12/24/2023.
Complaint Details
The complaint investigation was substantiated based on multiple staff interviews, video surveillance, and physical evidence of bruising on Resident #80. The accused CNA was terminated for verbal abuse and disruptive behavior.
Findings
The facility substantiated the allegation that CNA M verbally and physically abused Resident #80 by yelling at her, grabbing her scarf, and causing bruises. Multiple staff witnesses and video surveillance corroborated the abuse. CNA M was placed on administrative leave and subsequently terminated.
Deficiencies (1)
F 0600: The facility failed to protect Resident #80 from verbal, physical, and psychosocial abuse by staff, resulting in abuse and potential psychosocial harm.
Report Facts
Residents Affected: 1
Date of Incident: Dec 24, 2023
Date of Survey: Jan 26, 2024
Bruises noted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nursing Assistant | Accused of verbal and physical abuse of Resident #80; placed on administrative leave and terminated. |
| CNA F | Certified Nursing Assistant | Witnessed abuse and intervened to protect Resident #80. |
| CNA Z | Certified Nursing Assistant | Witnessed abuse and intervened. |
| LPN S | Licensed Practical Nurse, Charge Nurse | Conducted skin assessment of Resident #80 and escorted CNA M out of the building. |
| LPN HH | Licensed Practical Nurse | Reported disruptive behavior of CNA M and offered her a break. |
| Administrator | Executive Director | Abuse coordinator who reviewed video surveillance and addressed abuse concerns. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jan 26, 2024
Visit Reason
The investigation was conducted due to a complaint alleging verbal, physical, and psychosocial abuse of Resident #80 by a Certified Nursing Assistant (CNA M).
Complaint Details
The complaint involved allegations that CNA M verbally yelled at Resident #80, grabbed her scarf, and physically mishandled her, causing bruises. The allegation was substantiated based on staff interviews, video surveillance, and physical evidence of bruising. CNA M was placed on administrative leave and subsequently terminated.
Findings
The facility substantiated the allegation of verbal and mental abuse by CNA M towards Resident #80, including yelling and grabbing the resident's scarf, supported by staff interviews and video surveillance. CNA M was terminated. Additional deficiencies were found related to failure to complete a Level II PASARR evaluation for Resident #63, improper narcotic medication documentation for Residents #9 and #5, lack of annual nurse competency evaluations for several licensed nurses, improper medication labeling and storage, and failure to track and offer updated pneumococcal vaccines to residents.
Deficiencies (6)
F0600: The facility failed to protect Resident #80 from verbal, physical, and psychosocial abuse by staff, resulting in substantiated abuse and potential psychosocial harm.
F0644: The facility failed to ensure a Level II PASARR evaluation was completed for Resident #63, risking unmet mental health and psychiatric care needs.
F0658: The facility failed to ensure nursing staff signed out narcotic medications after administration for Residents #9 and #5, risking inaccurate documentation and medication mismanagement.
F0726: The facility failed to ensure 3 of 5 licensed nurses had current annual competency evaluations, placing resident safety at risk.
F0761: The facility failed to properly label, date, and store medications in 3 medication carts, risking decreased medication efficacy and exacerbation of medical conditions.
F0883: The facility failed to track and offer the updated pneumococcal vaccines (PCV15 or PCV20) to 3 residents, resulting in delayed opportunity to receive or decline vaccination.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Licensed nurses lacking competency evaluations: 3
Medication carts with labeling/storage issues: 3
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nursing Assistant | Named in verbal and physical abuse finding involving Resident #80; terminated from employment |
| CNA F | Certified Nursing Assistant | Witnessed abuse and intervened to protect Resident #80 |
| CNA Z | Certified Nursing Assistant | Witnessed abuse and intervened to protect Resident #80 |
| LPN S | Licensed Practical Nurse, Charge Nurse | Completed skin assessment of Resident #80 and involved in abuse investigation |
| RN G | Registered Nurse | Observed medication administration and noted narcotic count sheet errors |
| RN-UM SS | RN Unit Manager | Reported narcotic count sheet procedures and nurse competency evaluation requirements |
| DON | Director of Nursing | Reported on nurse competency evaluation process and responsibilities |
| RN D | Registered Nurse, Quality and Education Department | Reported on nurse competency evaluation attendance and makeup scheduling |
| IFP PP | Infection Preventionist | Reviewed immunization records and CDC guidelines for pneumococcal vaccines |
Inspection Report
Renewal
Census: 53
Capacity: 236
Deficiencies: 1
Date: Dec 18, 2023
Visit Reason
The inspection was conducted as a renewal licensing study to assess compliance with applicable rules and regulations for the facility's license renewal.
Findings
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.
Deficiencies (1)
Failure to have evidence of initial tuberculosis screening on record for Resident A prior to admission.
Report Facts
Number of staff interviewed and/or observed: 35
Number of residents interviewed and/or observed: 53
Facility capacity: 236
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 29, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of abuse and inadequate care, including failure to thoroughly investigate abuse allegations and failure to provide adequate supervision to prevent resident-to-resident physical altercations.
Complaint Details
The complaint investigation involved allegations of abuse and inadequate care for multiple residents, including failure to investigate abuse allegations thoroughly and failure to prevent resident-to-resident physical altercations. The allegations were substantiated in part, with findings of incomplete investigations and inadequate supervision.
Findings
The facility failed to thoroughly investigate allegations of abuse for multiple residents, resulting in incomplete investigations and potential for future mistreatment. The facility also failed to provide adequate supervision and interventions to prevent resident-to-resident physical altercations, leading to potential physical injury and psychosocial harm. Additionally, the facility failed to adequately assess and notify medical providers timely after falls with head injuries and did not perform adequate neurological monitoring for several residents.
Deficiencies (3)
The facility failed to thoroughly investigate allegations of abuse in 5 residents, resulting in incomplete investigations and potential for future mistreatment.
The facility failed to provide adequate supervision and implement interventions to prevent resident-to-resident physical altercations in 4 residents, resulting in potential physical injury and psychosocial harm.
The facility failed to adequately assess and notify the medical provider of a fall with head injury in a timely manner for 1 resident and failed to perform adequate neurological checks after falls for 3 residents, resulting in inadequate monitoring and potential for unnoticed injury.
Report Facts
Residents reviewed for abuse: 9
Residents involved in physical altercations: 4
Residents reviewed for accidents and falls: 4
Neurological assessments documented: 4
Redness area size: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Reported failure to conduct thorough investigations and inability to identify root causes for incidents |
| RN K | Registered Nurse | Reported involvement in incident investigations and care of residents involved in altercations |
| SW Y | Social Worker | Completed follow-up evaluations and reported lack of care plan interventions after incidents |
| LPN R | Licensed Practical Nurse | Reported care of Resident #106 after fall and issues with neurological checks |
| DON B | Director of Nursing | Reported missing neurological checks and expectations for hospital transfers after falls |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jan 11, 2023
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory standards related to resident safety, food safety, and facility policies.
Findings
The facility failed to develop and implement adequate policies and procedures for staff response to exit door alarms, proper food date marking and cleanliness, and maintenance of personal refrigerator temperature logs. These deficiencies posed risks of resident elopement, food contamination, and foodborne illness.
Deficiencies (3)
F 0689: 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 resident elopement on the 3rd floor.
F 0812: The facility failed to properly date mark potentially hazardous foods and clean food and non-food contact surfaces, increasing the risk of foodborne illness affecting 78 residents.
F 0813: The facility failed to follow its policy regarding maintenance of personal refrigerator temperature logs for one resident, resulting in missed temperature monitoring and potential food contamination.
Report Facts
Residents affected: 78
Missed temperature checks: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN KK | Registered Nurse | Named in door alarm response observation and interview |
| NM L | Nurse Manager | Named in door alarm response observation and interview |
| HSK NN | Housekeeper | Reported to have triggered door alarm by opening door for visitor |
| CNA GG | Certified Nursing Assistant | Reported hearing door alarm and not performing head count |
| DON | Director of Nursing | Provided expectations for staff response to door alarms |
| NHA | Nursing Home Administrator | Reported lack of policy on door alarm response |
| DM LL | Dietary Manager | Interviewed regarding food safety and date marking |
| HSK-S EE | Housekeeping Supervisor | Interviewed regarding housekeeping responsibilities and door alarm response |
| Chef MM | Chef | Interviewed regarding kitchen cleanliness and equipment |
| Facilities Services Supervisor DD | Facilities Services Supervisor | Interviewed regarding ice machine cleaning and maintenance |
| Unit Secretary H | Unit Secretary | Reported performing personal refrigerator checks |
| Registered Nurse Manager P | Registered Nurse Manager | Reported on electronic orders and personal refrigerator checks |
Inspection Report
Renewal
Deficiencies: 0
Date: Dec 20, 2022
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Wohlfert | Licensing Staff | Signed the renewal notification letter |
Inspection Report
Complaint Investigation
Capacity: 236
Deficiencies: 1
Date: Oct 27, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to complete an incident report and notify Resident A’s responsible person and physician of bruises observed on 9/22/22.
Report Facts
Capacity: 236
Complaint Receipt Date: Oct 13, 2022
Investigation Initiation Date: Oct 14, 2022
Inspection Date: Oct 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Myers | Administrator | Interviewed regarding the bruises on Resident A and facility procedures |
| Lauren Wohlfert | Licensing Staff | Author of the Special Investigation Report |
| Andrea L. Moore | Manager, Long-Term-Care State Licensing Section | Approved the report |
Inspection Report
Original Licensing
Capacity: 236
Deficiencies: 0
Date: Oct 15, 2018
Visit Reason
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.
Findings
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.
Report Facts
Licensed bed capacity decrease: 32
Licensed bed capacity: 236
Laundry equipment: 6
Laundry equipment: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Wohlfert | Licensing Staff | Completed the inspection and authored the report. |
| Russell Misiak | Area Manager | Signed the report and approved the recommendation. |
| Timothy Meyers | Administrator | Named as facility administrator in identifying information. |
| Troy Vugteveen | Authorized Representative | Named as authorized representative of the facility. |
Inspection Report
Original Licensing
Capacity: 265
Deficiencies: 0
Date: Oct 21, 2010
Visit Reason
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.
Findings
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.
Report Facts
Licensed capacity: 265
Day/dining space: 10455
Required day/dining space: 7950
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Russell B. Misiak | Licensing Staff | Author of the report and licensing staff conducting the inspection |
| Betsy Montgomery | Area Manager | Approved the report |
Inspection Report
Original Licensing
Capacity: 265
Deficiencies: 0
Date: May 9, 2005
Visit Reason
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.
Findings
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.
Report Facts
Bed increase: 17
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