Holland Home Raybrook Manor: Medication Safety Failure - MI
The admission came during a federal complaint inspection completed December 23, 2025. The nurse, identified in inspection records as LPN C, had pulled medications for Resident 103 and then, instead of discarding them when he couldn't administer them, stored them in his medication cart. That violated a basic rule he acknowledged knowing: you don't pull medications for more than one resident at a time, and if you can't give them, you throw them away and get replacements from the pharmacy.
He didn't do that.
What inspectors could not determine, and what the facility's own investigation could not confirm, was whether Resident 103 ultimately received the correct medications at all.
That uncertainty is the center of this story. LPN C told investigators he could have given Resident 103 the wrong medications. The Director of Nursing, identified as DON B, confirmed the facility launched an investigation after learning of that possibility. The investigation concluded without a definitive answer. Nobody could say with confidence that the right drugs went to the right person.
DON B confirmed to inspectors on December 22 that LPN C had not been following the rights of medication administration, and that storing the medications in the cart rather than discarding them was wrong. She did not dispute what her nurse had already told investigators about his own conduct.
LPN C's account of his own reasoning was unusually direct. He said he was overwhelmed. He said he was trying to get ahead of his workload. He said he knew, while he was doing it, that he was not storing or passing medications correctly. He said he understood that what he was doing increased the likelihood of a medication error. He said all of this to investigators himself.
The facility's medication administration policy, last revised in April 2024, is unambiguous on the relevant point. If medications are prepared but cannot be administered, the nurse discards them and contacts the pharmacy for replacement doses. The policy does not describe storing them in the cart as an option. It does not describe it as a fallback. It describes one course of action.
LPN C knew that course of action. He chose a different one.
Federal inspectors cited the violation under F0761, which covers medication storage and handling. The citation was tagged at a level of minimal harm or potential for actual harm, affecting a few residents. That designation reflects the lowest tier of harm in the federal rating system, but it does not mean nothing happened. It means inspectors could not confirm that something worse did.
The distinction matters less to Resident 103 than it might appear on a form. That resident was given medications by a nurse who, by his own account, was operating outside the boundaries of safe practice, who knew it, and who could not rule out afterward that the wrong drugs had been administered. The facility investigated and arrived at the same uncertain place.
There is no finding in the inspection report that Resident 103 was harmed. There is also no finding that they weren't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Holland Home - Raybrook Manor from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 19, 2026 · Our methodology
Holland Home - Raybrook Manor in Grand Rapids, MI was cited for violations during a health inspection on December 23, 2025.
The admission came during a federal complaint inspection completed December 23, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.