Holland Home - Raybrook Manor

Inspectors wroteThis citation pertains to intake #2808946. Based on interview and record review, the facility failed to ensure residents received care in accordance with professional standards in 3 residents (Resident #101, #103 & #106) of 6 residents reviewed for quality of care, resulting in an immediate jeopardy for 1 resident (Resident #101) when, beginning on 2/28/26 at approximately 8:00 AM, Resident #101 had an acute change of condition and staff failed to accurately assess, monitor and notify the physician, resulting in Resident #101 being transported to the hospital on 3/1/26 (approximately 24 hours later) due to unresponsiveness, hypertensive (high blood pressure) and fever. Resident #101 was evaluated and diagnosed with an acute basal ganglia hemorrhagic (bleeding in brain) stroke, admitted to the hospital and died on 3/8/26. [...]

Inspectors wroteThis citation pertains to intake #2808946. Based on interview and record review the facility failed to notify the physician/designee and resident's responsible party in a timely manner of significant changes in condition for 2 residents (Resident #101 and #103) out of 6 residents reviewed, resulting in a delay in care for an acute basal ganglia hemorrhagic (bleeding in brain) stroke for Resident #101 when the physician was not notified immediately of an acute change in condition and delay in care for Resident #103 when his responsible party was not notified of a fall and an acute change in condition until the resident was being sent to the hospital 2 days later.

Inspectors wroteBased on interview and record review, the facility failed to document vital signs during acute changes in condition for 2 residents (Resident #101 and #106) of 6 residents reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure wheelchairs were kept clean and/or in good repair for 6 (Residents # 2, 52, 36, 6, 46, and 29) of 6 residents reviewed for environment resulting in dirty wheelchairs, wheelchairs with missing or broken parts, and the potential for injury.

Inspectors wroteThis citation pertains to intake 2700015Based on interview and record review, the facility failed to protect the resident's right to be free from staff to resident verbal and threat of physical abuse in 1 (Resident #105) of 4 residents reviewed for abuse, resulting in Resident #105 being verbally abused by a staff member and the potential for a decline in mental and psychosocial well-being.

Inspectors wroteThis citation pertains to intake 2693805 and 2707404. Based on interview, and record review, the facility failed to properly store and dispose of medications for 1 (Resident #103) of 7 residents reviewed for medication storage resulting in the potential compromise of medications and/or misappropriation of medications, accidental ingestion, medication errors, and decreased efficacy of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1.) implement documented intervention and provide adequate supervision to prevent a fall for 1 (Resident #8) resident and 2.) safely transport 2 (Resident #27 and #42) residents in their wheelchairs with foot pedals of 5 residents reviewed for accidents/hazards/falls, resulting in a fall with fracture and a significant change in health status (Resident #8) and the potential for falls for Resident #27 and #42.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1.) protect the residents right to privacy for 1 (Resident #50) of 1 resident reviewed for privacy when staff entered the resident's room without knocking or asking for permission, 2). maintain the confidentiality of the Protected Health Information (PHI) when the Electronic Medical Record (EMR) was left open and unattended in a common area of the facility, resulting in 1.) feelings of frustration and embarrassment (Resident #50) and 2.) potential for unauthorized access to unsecured resident protected health information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the dry storage area and ensure proper labeling and dating of foods in the resident refrigerator in 2 dining rooms resulting in the potential to spread food borne illness to all residents that consume food from the kitchen and residents that store food in the dining room refrigerators.

Inspectors wroteBased on interview and record review, the facility failed to maintain dignity and respond to a resident's call light in a timely manner in 1 (Resident #76) of 3 residents reviewed for dignity, resulting in feelings of frustration and the potential for overall decline in quality of life.

Inspectors wroteBased on interview and record review, the facility failed to resolve resident concerns for 1 (Resident #34) of 1 sampled resident reviewed for resolution of concerns resulting in feelings of frustration and a potential decline in psychosocial and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of neglect to the State Agency in a timely manner for 1 (Resident #34) of 1 resident reviewed for neglect, resulting in the potential for continued violations involving neglect going undetected, unreported, or without thorough investigation.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise a person-centered care plan to reflect resident care needs for 1 (Resident #60) of 18 residents reviewed for care planning, resulting in an inaccurate reflection of resident care needs, and a potential for further injury and avoidable pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure special eating utensils were provided during meal times in 2 of 2 residents (Resident #55 & #30) reviewed for adaptive equipment, resulting in impaired ability to eat independently and the potential for weight loss.

Inspectors wroteDuring an interview on 2/05/2025 at 9:02 AM, Infection Preventionist (IP) N stated that when a resident was on Transmission Based Precautions (TBP), which included contact precautions (set of practices used to prevent the spread of infectious diseases through direct or indirect contact), Personal Protective Equipment (PPE) such as a gown and gloves should be worn by staff when going into the room whether it was to provide care, to deliver meal trays or just to talk to the resident. IP N said if a resident has gastrointestinal issues and was vomiting then staff should wear a mask too. She reported that with TBP rooms, PPE should be put on prior to entering the room and should be taken off prior to exiting the resident room. IP N stated that when staff was in a TBP room, they needed to wash their hands with soap and water before they exited the room. [...]

Inspectors wroteThis citation pertains to intake #MI00142031 Based on interviews and record review, the facility failed to protect the resident's right to be free from verbal, physical and psychosocial abuse by staff, resulting in abuse and the potential of psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for 1 (Resident #63) of 1 residents reviewed for PASARR Screening, resulting in the potential for unmet mental health and psychiatric care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received care in accordance with professional standards of nursing practice for 2 residents (Resident #9 and #5) of 6 residents reviewed for standard of care when nursing staff failed to sign out narcotic medications after dispensing and administering the medications resulting in inaccurate documentation and the potential for health complications and mismanagement of narcotic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, date, and store medications in 3 out of 3 medication carts reviewed for medication storage and labeling resulting in the potential for decreased efficacy of medications and the exacerbation of medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to track and offer the pneumococcal vaccine for 3 (Resident #38, #47, and #57) of 5 residents reviewed for immunizations, resulting in a delay in the residents being given the opportunity to receive or decline the pneumococcal vaccination.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 of 5 licensed nurses had the necessary skills and competencies to provide nursing care in accordance with professional standards, resulting in the physical and psychosocial health and safety of residents being placed at risk.

Inspectors wroteThis citation pertains to intake MI00136996, MI00136998, and MI00140782. Based on interview and record review, the facility failed to thoroughly investigate allegations of abuse in 5 (Resident #101, #102, #103, #104, and #105) of 9 residents reviewed for abuse resulting in incomplete abuse investigations and the potential for future mistreatment and/or abuse.

Inspectors wroteThis citation pertains to intake MI00136996, MI00136998, MI00140782 Based on interview and record review the facility failed to provide adequate supervision and implement interventions to prevent resident to resident physical altercations in 4 (Resident #101, #102, #103, and #104) of 9 residents reviewed for abuse, resulting in the potential for physical injury, unmet care needs, fear, anxiety, and a decline in psychosocial wellbeing.

Inspectors wroteThis citation pertains to intake MI00138827. Based on interview and record review, the facility failed to 1) adequately assess and notify the medical provider of a fall with head injury in a timely manner for 1 resident (Resident #106) of 4 residents reviewed for accidents and falls and 2) perform adequate monitoring and neurological checks after falls for 3 residents (Resident #106, #108, and #101) of 4 residents reviewed for accidents and falls, resulting in inadequate monitoring, a delay in emergency treatment, and the potential for unnoticed and untreated physical injury.