Holland Home - Raybrook Manor

In the surveyor’s words

From the most serious findings on record at Holland Home - Raybrook Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jun 24, 2026

  This 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. […]

• Actual harm, isolatedF689Feb 5, 2025

  Based 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. Findings include: Resident #8 Review of an Admission Record revealed Resident #8 was a female, with pertinent diagnoses which included: fracture of nasal bones (1/23/25), other fracture of third [NAME] (lumbar) vertebra (1/23/25). […]

• Actual harm, isolatedF689Aug 12, 2022

  This citation pertains to intake MI 022. Based on observation, interview, and record review the facility failed to ensure a gait belt was used during ambulation for 1 (Resident #6) of 4 residents reviewed for falls resulting in pain, hospitalization , and a subdural hematoma (bleed that occurs within your skull but outside the brain tissue) for Resident #6. Findings include: During an observation and interview on 8/10/22 at 9:30 AM, Resident #6 reported she fell last month, she hit her head, went to the hospital, and she had stitches in the right side of her head. Resident #6 stated the stitches came out a few days ago and reported it was painful when she fell . Resident #6 was observed seated upright in her recliner chair in her room watching television. […]

• Actual harm, isolatedF689Sep 8, 2021

  This citation pertains to Intake: MI 345 Based on interview and record review, the facility failed to provide adequate supervision and implement appropriate care planned interventions to prevent a fall in 1 of 5 residents (Resident #102) reviewed for falls, resulting in a fall with laceration injury to the resident's head and Findings include: Review of Incident Summary dated 8/19/2021, revealed, .Resident had a fall during either a repositioning in bed or transfer out of bed in her room on 8-18-2021 at approximately 9:10pm. (Unit Manager G) discovered possible root cause, during post-fall review, may have been a one person transfer by the (CNA C), when the care guide indicates transfers with two assist. Investigation initiated and employee placed on administrative leave. […]

• No harm, potential for more than minimal, widespreadF583Feb 5, 2025

  Based 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. […]