Cycle 1
Health 2025-02-05 · Fire 2025-02-05
11 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Grand Rapids, MI
Holland Home - Raybrook Manor
4-star overall rating with 2-star inspections with abuse icon flag with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2121 Raybrook SE, Grand Rapids, MI
(616) 235-5702
Overall
4 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
101
Certified beds
Average residents
88
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1985-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.94
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
3.07
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
4.79
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
4.23
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.97
CMS adjusted RN staffing hours
Adjusted total hours
4.97
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
591
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.92
Composite VBP score used to determine payment impact.
Payment multiplier
1.0206
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.7
Baseline 32.82% · Performance 36.30% · Measure score 6.7 · Achievement 6.7 · Improvement 0
Adjusted total nurse staffing
6.69
Baseline 5.22 hours · Performance 4.98 hours · Measure score 6.69 · Achievement 6.69 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.41% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 6.38% · Lower 95% interval 6.63% |
| Discharge to community | 24.3% |
50.57%
26.3 pts worse
|
Worse than the National Rate · Eligible stays 35 · Observed rate 8.57% · Lower 95% interval 14.1% |
| Medicare spending per beneficiary | 0.62 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.86% |
8.2%
1.3 pts worse
|
Numerator 14 · Denominator 204 |
| Staff flu vaccination coverage | 47.5% |
42%
5.5 pts better
|
Numerator 95 · Denominator 200 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.7
0.4 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.4 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.5
0.9 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.4 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
95.0%
4.7 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.6% |
95.0%
0.6 pts better
|
95.5%
0.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.1%
0.9 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.1% · Q3 3.8% · Q4 2.5% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
4.1%
2.5 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.4% · Q3 1.4% · Q4 2.5% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.5%
2.4 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 12.7% · Q3 7.7% · Q4 6.5% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.1% |
19.6%
5.5 pts better
|
19.6%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 15.9% · Q3 13.8% · Q4 12.7% · 4Q avg 14.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.6% |
16.5%
1.9 pts better
|
16.7%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 15.4% · Q3 15.8% · Q4 14.0% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.4% |
13.9%
9.5 pts better
|
16.3%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.9% · Q3 2.7% · Q4 5.2% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.0% |
11.7%
8.7 pts better
|
14.9%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.4% · Q3 3.4% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
20.4%
1 pts worse
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 23.7% · Q3 21.9% · Q4 18.4% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.6%
1.4 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 8.5% · Q3 5.7% · Q4 7.0% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
82.8%
12.2 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 91.3% · Q3 98.1% · Q4 100.0% · 4Q avg 95.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.3%
About the same
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 5.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.6% |
79.5%
16.1 pts better
|
79.7%
15.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-01-11 · Fire 2023-01-11
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-11
F · Potential for more than minimal harm
2024-01-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-27
F · Potential for more than minimal harm
2024-01-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-01-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-01-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-01-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-01-26
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-01-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-27
F · Potential for more than minimal harm
2023-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-15
E · Potential for more than minimal harm
2023-01-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-15
E · Potential for more than minimal harm
2023-01-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-15
E · Potential for more than minimal harm
2023-01-11
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2023-02-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-01-27
D · Potential for more than minimal harm
2025-12-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2026-01-27
G · Actual harm
2025-02-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-11
F · Potential for more than minimal harm
2025-02-05
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-03-11
F · Potential for more than minimal harm
2025-02-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-05
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-05
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-11
D · Potential for more than minimal harm
2024-01-26
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-02
D · Potential for more than minimal harm
2024-01-26
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-26
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-26
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-01-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-27
B · Minimal harm
2024-01-26
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-02-27
E · Potential for more than minimal harm
2023-11-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-02
E · Potential for more than minimal harm
2023-11-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-11-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-18
F · Potential for more than minimal harm
2023-01-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-15
E · Potential for more than minimal harm
2023-01-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-15
D · Potential for more than minimal harm
2023-01-11
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-02-15
Penalties and ownership
What sits behind the stars
$0
2025-02-05
Payment Denial
Payment Denial · denial start 2025-03-01 · 10 days
10 day denial
Ownership
Christian Living Services
Operational/Managerial Control · Organization
Duemler, Ronald
Contracted Managing Employee · Individual
Farr, Paul
Corporate Director · Individual
Hidalgo, Carlos
Corporate Director · Individual
Johnson, Mark
Corporate Director · Individual
Kinder, Adam
Corporate Officer · Individual
Knibbe, David
Corporate Director · Individual
Malburg, Gary
Corporate Director · Individual
Matro, Philip
W-2 Managing Employee · Individual
Myers, Timothy
W-2 Managing Employee · Individual
Nagelkerk, Jean
Corporate Director · Individual
Sanchez, Nelson
Corporate Director · Individual
Segovia, Gilbert
Corporate Director · Individual
Smith, David
Corporate Director · Individual
Thole, Nick
Corporate Director · Individual
Ursul, Mary
Corporate Director · Individual
Vogel-Vanderson, Susan
Corporate Director · Individual
Vugteveen, Troy
Corporate Director · Individual
Vugteveen, Troy
Corporate Officer · Individual
Watson, Sam
Corporate Director · Individual
Nearby options
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#2
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5-star overall rating with 5-star inspections with 2 recent health deficiencies
#3
Mission Point Nursing & Physical Rehabilitation Ce
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2-star overall rating with 2-star inspections with $55,219 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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