Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holland Home - Raybrook Manor during CMS and state inspections, most recent first.
Wheelchairs were found soiled or missing/broken parts for multiple residents with severely impaired cognition. A resident’s chair had dried brown/pink buildup on the frame, seat, cushion, and wheels with no cleaning documented for weeks, while other residents had broken or missing foot pedal straps, a missing anti-tip bar, or an anti-tip bar that was misaligned. The DON and NHA confirmed the cleaning and equipment issues observed by surveyors.
A resident with dementia and behavioral challenges was verbally abused by an RN, who made threatening statements in response to the resident's wandering and attempts to access the medication cart. Multiple staff witnessed and reported the incident, and the facility's investigation substantiated the verbal abuse, which was in violation of the facility's abuse policy.
A nurse failed to discard prepared medications when a resident was unavailable, instead storing them in a medication cart drawer alongside another resident's medications. Upon the resident's return, the nurse administered the previously prepared medications, after which the resident became unresponsive and required hospital transfer for a possible medication overdose. Facility leadership confirmed that the nurse did not follow proper medication administration protocols, including not discarding unused medications and not preparing medications for more than one resident at a time.
A resident fell and sustained serious injuries due to the facility's failure to implement necessary interventions and provide adequate supervision. Additionally, two residents were unsafely transported in wheelchairs without proper use of foot pedals, contrary to facility policy, posing a risk of injury.
A facility failed to protect resident privacy and confidentiality in two incidents. A laptop displaying PHI was left unattended in a common area, and a resident reported staff entering her room without knocking, including an LPN administering insulin while she was on the toilet. The resident, with major depressive and anxiety disorders, had previously complained about privacy breaches.
The facility failed to maintain sanitary conditions in the dry storage area and ensure proper labeling and dating of foods in resident refrigerators. Observations included leaking containers in the dry storage and unlabeled, undated food items in resident refrigerators. The Dining Services Manager acknowledged the oversight, indicating a lapse in compliance with food safety protocols.
A resident experienced significant delays in call light response times, ranging from 27 to 62 minutes, despite the facility's goal of responding within 5 to 10 minutes. The resident, who was cognitively intact and dependent on staff for toilet transfers due to sciatica and urinary incontinence, reported frustration and distress due to these delays, as she often needed urgent assistance.
A resident with functional urinary incontinence reported being left in a wet brief for hours, particularly during night shifts, leading to frustration and distress. Despite being aware of the grievances, the facility staff, including the NHA, Social Worker, and Unit Manager, failed to document or resolve the issues as per the facility's grievance policy. The lack of follow-up and investigation left the resident's concerns unaddressed.
A resident reported being left in a wet brief for hours, particularly during night shifts, and voiced concerns to management without resolution. The NHA did not report these concerns to the State Agency, believing they were care-related rather than neglect, and no investigation was conducted. The facility's policy requires timely reporting and investigation of neglect allegations, which was not followed.
A resident with severe cognitive impairment and a recent right humerus fracture had an outdated care plan that included inappropriate interventions requiring the use of both arms. Despite physician orders for a sling and restricted movement, the care plan was not updated, leading to potential for further injury and avoidable pain. Staff interviews revealed a lack of communication and action to revise the care plan.
Two residents in a facility were not provided with necessary adaptive eating equipment, as specified in their care plans, due to the use of disposable utensils during an illness outbreak. One resident with arthritis and dementia did not receive built-up silverware, while another with dysphagia and Parkinson's disease was not given red foam on silverware, leading to difficulties in eating independently.
The facility failed to implement proper infection control measures, as staff entered rooms under transmission-based precautions without appropriate PPE. Observations and interviews revealed a lack of awareness and communication regarding residents' precautionary status, and insufficient training on PPE use and hand hygiene during a norovirus outbreak. This led to potential cross-contamination risks.
Wheelchairs Left Soiled or in Disrepair
Penalty
Summary
The facility failed to ensure wheelchairs were kept clean and in good repair for six residents who were reviewed for environment. The report documented dirty wheelchairs, missing or broken wheelchair parts, and wheelchairs with components that were not secured as intended. The residents involved had severely impaired cognition and were unable to answer questions about the condition of their wheelchairs. Resident #2 was observed multiple times with a wheelchair that was visibly soiled with dried brown/pink material on the frame, seat, cushion, and wheels, including the hand rims used to propel the chair. The wheelchair remained soiled across several observations, and the facility’s weekly wheelchair cleaning logs did not show that the wheelchair had been cleaned for the past 30 days. An email from the DON stated there was no documentation available to show when the wheelchair was last cleaned, and the facility’s cleaning schedule contained no documentation that the wheelchair had been cleaned. Resident #52’s wheelchair had a broken right foot pedal strap that was not attached on the inner side and rested on the floor, and the left foot pedal had no heel strap present. Resident #36’s wheelchair seat was soiled with brown and white debris and chunks of material that appeared to be old food, and the right anti-tip bar was missing during repeated observations. The DON confirmed the wheelchair had not been cleaned for the past 30 days, and the NHA stated the anti-tipper bars were discontinued on 3/11/26 and that the wheelchair should have had both anti-tip bars in place before removal. Resident #6’s wheelchair had brown and pink material built up on the frame, wheel lock, front wheel, and cushion. Resident #46’s left anti-tip bar was misaligned and angled inward instead of positioned straight back and down. Resident #29’s right foot pedal heel strap was not secured and rested on the floor, and there was no heel strap on the left foot pedal.
Resident Verbally Abused by Staff Member
Penalty
Summary
A resident with diagnoses including unspecified dementia and major depressive disorder, who exhibited behaviors such as wandering, entering other residents' rooms, and attempting to access the medication cart, was subjected to verbal abuse by a registered nurse. The nurse, in response to the resident's wandering and approaching the medication cart, made threatening statements including, "I'm going to kick your a**" and "When I quit or get fired, I'm going to kick your a**." These statements were witnessed by multiple staff members, who immediately reported the incident to facility leadership. The facility's investigation, corroborated by four eyewitness accounts, substantiated that the nurse verbally abused the resident. The facility's abuse policy defines verbal abuse as the use of disparaging or derogatory language toward residents, regardless of their ability to comprehend. The nurse involved resigned during the investigation. The incident resulted in the resident being verbally abused by a staff member, with the potential for a decline in the resident's mental and psychosocial well-being.
Improper Storage and Administration of Medications Resulting in Potential Medication Error
Penalty
Summary
A deficiency occurred when a nurse failed to properly store and dispose of medications for a resident with Alzheimer's disease and type 2 diabetes. The nurse prepared the resident's evening medications but, upon discovering the resident was not present, placed the medications in the top drawer of the medication cart instead of discarding them as required by facility policy. Another medication cup for a different resident was also present in the same drawer, creating confusion about which medications were administered. Subsequently, the nurse administered the previously prepared medications to the resident when he returned, after which the resident became unresponsive and required hospital transfer for a possible medication overdose. Facility staff and emergency medical services were unable to confirm whether the resident had received the correct medications or another resident's medications, as the nurse could not verify what had been administered. The nurse acknowledged that he was overwhelmed and did not follow proper medication administration protocols, including not preparing medications for more than one resident at a time and not discarding unused medications. Interviews with facility leadership confirmed that the nurse's actions were not in accordance with the rights of medication administration and the facility's medication management policy. The policy specifically states that medications unable to be administered after preparation must be discarded, and that medications should not be pre-set for more than one resident at a time. The failure to follow these procedures resulted in the potential compromise of medication safety for the resident involved.
Failure to Prevent Falls and Ensure Safe Wheelchair Transport
Penalty
Summary
The facility failed to implement documented interventions and provide adequate supervision to prevent a fall for a resident, resulting in a fall with a fracture and a significant change in health status. The resident, who had a history of falls and was at high risk due to impaired mobility and cognitive impairment, attempted to ambulate without assistance and fell, sustaining facial trauma and fractures. The care plan did not reflect the necessary intervention to remove items with wheels, which the resident used as a walker, contributing to the fall. Additionally, the facility failed to safely transport two residents in their wheelchairs. Observations revealed that staff did not use foot pedals when moving these residents, which is against the facility's policy and poses a risk of injury. One resident was observed being pushed without foot pedals, and another had foot pedals attached but not properly used, leaving their feet hovering above the floor. Staff interviews confirmed that the use of foot pedals is required for safety, yet this practice was not consistently followed. The deficiencies highlight a lack of adherence to safety protocols and inadequate supervision, which resulted in a fall with serious injuries for one resident and potential risks for others. The facility's failure to ensure the proper use of wheelchairs and to implement necessary interventions for fall prevention contributed to these incidents.
Privacy Breach and Unattended PHI in Facility
Penalty
Summary
The facility failed to protect the privacy and confidentiality of residents' personal and medical records in two distinct incidents. In the first incident, a laptop displaying protected health information (PHI) was left open and unattended on a medication cart in a common area, visible to passersby for six minutes. This lapse was acknowledged by the responsible Registered Nurse (RN), who admitted to forgetting to secure the laptop due to being busy. The Director of Nursing (DON) confirmed this was a breach of privacy expectations. In the second incident, a resident, who was cognitively intact and diagnosed with major depressive disorder and generalized anxiety disorder, reported that staff entered her room without knocking, compromising her privacy. The resident recounted an instance where a Licensed Practical Nurse (LPN) administered insulin while she was on the toilet, which she found disrespectful. The resident had previously complained to the social worker about staff not knocking before entering, and a sign had been put up, though it was unclear if it remained. The social worker confirmed the resident's complaints but was unaware of the insulin administration incident.
Sanitation and Food Labeling Deficiencies in Dining Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the dry storage area and ensure proper labeling and dating of foods in the resident refrigerators in two dining rooms. During a kitchen tour, it was observed that a 64 fluid ounce bottle of white vinegar was dripping from the cap onto the shelf, and a box of grape juice concentrate was leaking onto a box of apple juice concentrate below. These conditions indicate a lack of adherence to proper storage and sanitation protocols, which could potentially lead to the spread of foodborne illness among residents consuming food from the kitchen. Additionally, during a tour of the resident refrigerators, it was found that food items were not properly labeled or dated. On the 3rd floor, a plastic bag labeled with a room number contained open baby carrots, lettuce, and sweet potatoes without any indication of the open date or use-by date. On the 4th floor, uncovered blueberries were found in a styrofoam cup. The Dining Services Manager acknowledged that these items should have been labeled and dated or discarded if not labeled, and stated that while nursing staff should label and date resident food items, the kitchen holds ultimate responsibility. This lack of compliance with the facility's policy and FDA Food Code requirements poses a risk of cross-contamination and food safety issues.
Delayed Call Light Response Affects Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident by not responding to her call light in a timely manner. The resident, who was cognitively intact with a BIMS score of 13, was dependent on staff for toilet transfers due to lower extremity weakness associated with sciatica and occasional urinary incontinence. The resident reported that it sometimes took up to an hour for staff to respond to her call light, causing frustration as she often needed to use the bathroom urgently. The resident also mentioned hearing staff conversing in the hallway while waiting for assistance. The Alarm History Report for the resident showed multiple instances of delayed response times, ranging from 27 to 62 minutes, far exceeding the facility's goal of responding within 5 to 10 minutes. Interviews with the RN and DON confirmed that the expected response time was less than 10 minutes, ideally 5 minutes or less. These delays in response time contributed to the resident's feelings of frustration and potentially impacted her quality of life.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to resolve the grievances of a resident, identified as Resident #34, who was admitted with a diagnosis of functional urinary incontinence. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, Resident #34 expressed concerns about being left in a wet brief for extended periods, particularly during the night shift. The resident reported these issues to management but felt that no action had been taken, leading to feelings of frustration and distress. The Nursing Home Administrator (NHA) was aware of the resident's concerns through an email from the Vice President of Operations, which highlighted unresolved care issues and specific staff members involved. However, there was no documentation of any grievance forms or follow-up actions taken by the facility's staff, including the Social Worker and Unit Manager, who were responsible for addressing these concerns. The Unit Manager admitted to not investigating the allegations or reviewing available evidence, such as camera footage, to verify the resident's claims. The facility's grievance policy outlines the process for addressing resident complaints, but in this case, it was not followed. The Director of Nursing was not involved in the follow-up, and the NHA confirmed that no care conference or staff education had been documented. The lack of documentation and follow-up actions indicates a failure to adhere to the facility's policy, leaving the resident's grievances unresolved and unaddressed.
Failure to Report Allegations of Neglect in a Timely Manner
Penalty
Summary
The facility failed to report allegations of neglect to the State Agency in a timely manner for a resident who was reviewed for neglect. The resident, who was cognitively intact, reported concerns about being left in a wet brief for hours at a time, particularly during the night shift. Despite voicing these concerns to management, the resident continued to experience the same issues. The Nursing Home Administrator (NHA) did not have any concern or grievance forms for the resident but had sent an email to the facility's Interdisciplinary Team regarding the resident's family's meeting with the President of Operations to discuss unresolved care concerns. The NHA admitted to not reporting the resident's concerns to the State Agency, believing they were more care-related rather than neglect. The NHA did not consider the situation as potential neglect unless there was an injury or another negative outcome. Consequently, no investigation was conducted regarding the resident's concerns. The facility's Abuse and Neglect Policy requires all alleged violations involving neglect to be thoroughly investigated and reported to the State Agency within specified timeframes, which was not adhered to in this case.
Failure to Update Care Plan for Resident with Fracture
Penalty
Summary
The facility failed to update the care plan for a resident who had recently suffered a right humerus fracture. The resident, who was severely cognitively impaired with a BIMS score of 2/15, was observed sitting in a wheelchair with a sling on her right arm. Despite the fracture, the care plan still included interventions that required the use of both upper extremities, such as ambulating with a four-wheeled walker and using exercise equipment. These interventions were no longer appropriate given the resident's condition. Interviews with facility staff revealed a lack of communication and action regarding the resident's updated care needs. The Case Manager confirmed that the resident should not exercise or bear weight on her right arm, and the Unit Manager acknowledged that the care plan should have been updated following the resident's injury and the physician's orders for a sling. The care plan did not provide guidance for staff on the resident's physical restrictions or the use of the sling, leading to potential for further injury and avoidable pain.
Failure to Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating utensils and adaptive equipment to two residents, resulting in impaired ability to eat independently. Resident #55, who has arthritis, depression, and dementia, was not provided with built-up silverware as specified in his care plan. Despite the facility's use of disposable utensils due to a gastrointestinal illness outbreak, the resident's care plan required built-up utensils to assist with eating. Observations confirmed that Resident #55 was consistently served meals with disposable cutlery, and interviews with family and staff corroborated the lack of appropriate utensils. Resident #30, diagnosed with dysphagia and Parkinson's disease, was also affected by the facility's failure to provide necessary adaptive equipment. His care plan specified the use of red foam on silverware to aid in self-feeding, but observations revealed that this equipment was not provided during meals. Interviews with the resident and staff confirmed that the absence of the red foam made it difficult for Resident #30 to eat independently, as he struggled to keep food on his utensils. The facility's policy on meal delivery emphasizes the importance of providing necessary assistance and adaptive equipment to promote nutritional health. However, due to the illness outbreak, the facility opted for disposable utensils, neglecting the specific needs outlined in the residents' care plans. This oversight resulted in both residents experiencing difficulties in eating independently, highlighting a failure to adhere to individualized dietary needs and care plans.
Inadequate Implementation of Infection Control Measures
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, specifically in the use of personal protective equipment (PPE) and hand hygiene practices in rooms under transmission-based precautions (TBP). Observations revealed that staff members, including Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs), entered rooms with residents suspected of having norovirus without donning the required PPE such as gowns and gloves. This was despite the presence of signs indicating contact precautions, which were sometimes found on the floor or not visible to staff. Interviews with staff members, including CNAs and the Unit Manager, indicated a lack of awareness and communication regarding which residents were under contact precautions. The report sheets used for shift changes did not consistently reflect the current status of residents under TBP, leading to confusion among staff. Additionally, there was a noted absence of recent training or education provided to staff on the proper use of PPE and hand hygiene practices during the norovirus outbreak. The Infection Preventionist confirmed that PPE should be worn by staff when entering TBP rooms, and hand hygiene with soap and water is necessary after caring for residents with gastrointestinal issues like norovirus. However, observations and interviews highlighted that these practices were not consistently followed, as some staff members relied on hand sanitizer instead of soap and water. The lack of adherence to established protocols and insufficient communication and training contributed to the potential for cross-contamination and the spread of infectious diseases within the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Grand Rapids
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health & Rehabilitation At Kent-crossing | 0.3 mi | ★★★★★ | 33 | 0 |
| Valley Health Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Beacon Hill At Eastgate | 1.9 mi | — | 2 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 2 mi | ★★★★★ | 0 | 0 |
| Optalis Health And Rehabilitation Of Grand Rapids | 2.1 mi | ★★★★★ | 34 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.