Holland Home - Raybrook Manor
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
abuse towards Resident #105, but that RN K told her that she was being investigated for allegations of verbal abuse. LPN P reported RN K told her that she would never actually do that; she was just joking around. This writer attempted to contact RN K on 12/22/25 at 12:59 PM. RN K did not return this writer's call at time of survey exit. During an interview on 12/22/25 at 11:28 AM, Nursing Home Administrator (NHA)
A reported he had conducted the investigation for the allegations of verbal abuse from RN K towards Resident #105. NHA A confirmed that he had substantiated that Resident #105 was verbally abused by RN K. NHA A reported that RN K resigned during the investigation. Review of the facility's Abuse Policy last revised 9/2022 revealed, POLICY: Each resident has the right to be free from abuse and neglect. To provide
a safe environment for residents, to promote respect, and to set standards of care, the facility will monitor for abuse and investigate all allegations of resident abuse . Definitions: . Verbal Abuse refers to any use of oral, written or gestured language that includes disparaging and/or derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend, or disability .
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
12/23/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Holland Home - Raybrook Manor
2121 Raybrook SE Grand Rapids, MI 49546
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0761
F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
medications to Resident #103. LPN C confirmed that he should have discarded Resident #103's medications, and that he knew that he was not supposed to pull medications for more than one resident at
a time. LPN C reported that he was busy, overwhelmed, and trying to get ahead, and he knew he was not storing or passing medications correctly, and his likelihood for causing a medication error were increased due to this. During an interview on 12/22/25 at 1:50 PM, Director of Nursing (DON) B reported she had been made aware that LPN C reported that he could have given Resident #103 the wrong medications.
DON B confirmed that the facility conducted an investigation into the potential medication error, but that
they could not confirm if Resident #103 had been given the wrong medications. DON B confirmed that LPN C was not following the rights of medication administration and he should have discarded Resident #103's medication instead of storing them in the medication cart. Review of the facility's Medication Administration Policy last revised April 2024 revealed, POLICY: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions . Procedures: . Administration:
- 14. If medications are unable to be administered after preparation, the nurse will discard those medications
and contact the pharmacy for replacement doses .
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Holland Home - Raybrook Manor in Grand Rapids, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Grand Rapids, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Holland Home - Raybrook Manor or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.