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STATE OF MICHIGAN GRETCHEN WHITMER DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS ORLENE HAWKS GOVERNOR DIRECTOR LANSING March 19, 2021 Rose Bouck 12700 Lincoln Lake Rd Gowen, MI 49326 RE: License #: AF410395782 Investigation #: 2021A0357012 Country Acres Dear Ms. Bouck: Attached is the Special Investigation Report for the above referenced facility. Due to the violations identified in the report, a written corrective action plan was required. However, on 03/19/2021 you submitted a statement indicating that in lieu of a corrective action plan, you have decided to discontinue providing adult foster care and requested that your license be closed. Your written request to close your license along with the understanding that you are no longer providing adult foster care services has been accepted in lieu of a Corrective Action Plan. As a result your license will be closed effective on 03/19/2021. Please review the enclosed documentation for accuracy and contact me with any questions. Sincerely, Arlene B. Smith, MSW, Licensing Consultant Bureau of Community and Health Systems, Unit 13, 7th Floor 350 Ottawa, N.W., Grand Rapids, MI 49503 (616) 916-4213 enclosure 611 W. OTTAWA P.O. BOX 30664 LANSING, MICHIGAN 48909 www.michigan.gov/lara 517-335-1980 MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF COMMUNITY AND HEALTH SYSTEMS SPECIAL INVESTIGATION REPORT This report contains quoted profanity. I. IDENTIFYING INFORMATION License #: AF410395782 Investigation #: 2021A0357012 Complaint Receipt Date: 01/04/2021 Investigation Initiation Date: 01/04/2021 Report Due Date: 03/05/2021 Licensee Name: Rose Bouck Licensee Address: 12700 Lincoln Lake Rd, Gowen, MI 49326 Licensee Telephone #: (616) 302-5702 Name of Facility: Country Acres Facility Address: 12700 Lincoln Lake Rd, Gowen, MI 49326 Facility Telephone #: (616) 712-6002 Original Issuance Date: 11/01/2018 License Status: REGULAR Effective Date: 05/01/2019 Expiration Date: 04/30/2021 Capacity: 6 Program Type: PHYSICALLY HANDICAPPED, TRUMATICALLY BRAIN INJURED, DEVELOPMENTALLY DISABLED, MENTALLY ILL, AGED, ALZHEIMERS 1 II. ALLEGATION(S) Violation Established? There is yelling and swearing in front of residents. Yes Light bulbs in resident rooms are removed at night to prevent Yes residents from staying up too late. Resident A was locked in her bedroom. Yes The home was found with an excessive amount of unused resident medications. Ms. Wagner yells and screams at Resident E. No Ms. Bouck told Resident E he was not safe in the home, bitches at No him, tells Resident B to shut up, and makes him stay in his room. III. METHODOLOGY 01/04/2021 Special Investigation Intake 2021A0357012 01/04/2021 Special Investigation Initiated - Telephone to Recipient Rights, Edward Wilson, network 180, Kent County 01/04/2021 Contact - Telephone call received From Rose Bouck, the Licensee, with a long history between Fran Wagner and their family members. 01/04/2021 Contact- APS Referral to Kent County. 01/05/2021 Contact - Telephone call made With Rose Bouck, the Licensee. 01/05/2021 Contact - Telephone call made With Fran Wagner, the Responsible Person/ property owner. 02/15/2021 Contact – Telephone call received\ From Behavioralist Cora. 01/23/2021 Contact - Document Received Received a video from Rose Bouck. 01/23/2021 Contact - Telephone call received From Rose Bouck 01/23/2021 Contact - Telephone call received From Rose Bouck. 01/26/2021 Contact - Document Received 2 Rose Bouck faxed me documents from Resident A's file including, face sheet, IPOS, Resident Care Agreement, Health Care Appraisal, Sparks Behavioral Services L.L.C., Behavioral Treatment Plan with revision, (Baseline Data): SIB (head hitting), Rectal Digging, Skin Picking, Drink swiping, Object swiping, Resident A is non-verbal. 01/27/2021 Contact - Document Received Received video 01/29/2021 Contact - Telephone call received From Rose Bouck. 01/29/2021 Contact - Telephone call received From Rose Bouck. 01/29/2021 Contact - Telephone call made Telephone interview with Resident E. 02/02/2021 Contact - Document Received Received a text message from Rose Bouck. 02/02/2021 Contact - Telephone call made Conducted interviews with staff, Nicole Brzak and Sherry Bartlett. 02/04/2021 Contact - Telephone call made To staff Brittanie Rogers, Ms. Wagner’s niece. 02/05/2021 Contact - Telephone call received Received telephone from Rose Bouck with more information. 02/05/2021 Contact - Telephone call received From Rose Bouck. 02/09/2021 Contact - Telephone call received From Bob Patterson, Recipient Rights, network 180. 02/09/2021 Contact - Telephone call made To Resident A's Behavioral Specialist, Cora Santman. 02/10/2021 Contact - Telephone call made Telephone call made to Sharon Kosters, Public Guardian for Resident A. 02/10/2021 Contact - Document Received Sharon Kosters 3 02/11/2021 Contact - Face to Face Interview with Frances Wagner concerning the complaints at Country Acres. 02/16/2021 Contact - Document Received Rose Bouck 02/16/2021 Contact - Document Received Received pictures of resident's medication cards and bottles from Angela Loiselle, Recipient Rights Director, from Montcalm Care Network. 02/16/2021 Contact document received from Michelle Richardson Sent four more Recipient Rights Complaints. 02/16/2021 Contact - Telephone call made To Recipient Rights, Edward Wilson and Michelle Richardson and discussed the complaints. 02/17/2021 Inspection Completed On-site I met Edward Wilson at the home and we interviewed Ms. Bouck, and Resident A. 02/17/2021 Inspection Completed On-site Interviewed Rose Bouck. A Detective came from the Kent County Sheriff's Office, Detective Stanton. 02/17/2021 Contact - Document Received Edward Wilson provided me with a copy of the complaint for Resident's medications that were stored in the home. 02/18/2021 Contact - Telephone call received From Rose Bouck. 02/19/2021 Inspection Completed On-site I met with Rose Bouck. 02/23/2021 Contact - Document Received Email received from Tae Naumes, Contract Manager for network 180, terminating Ms. Bouck’s CLS contract on 02/24/2021. 02/24/2021 Contact - Document Received Received email from Drew Blackall, APS, Kent County 02/25/2021 Contact - Document Received 4 Drew Backall sent an email that Resident A has moved into a new home. 03/03/2021 Contact – Telephone call made to L T C Pharmacy and interviewed Matthew Aldrich. O3/03/2021 Contact – Email received with the MAR’s of Resident A, B, C, D, and E. I reviewed the MAR’s. 03/08/2021 Contact – Telephone call made to Michelle Richardson, Recipient Rights, network 180. 03/11/2021 Contact – Telephone call made to Michelle Richardson, Recipient Rights, network 180. 03/17/2021 Contact – Telephone call made to Cora Santman, Behavioral Specialist, Rose Bouck, Licensee and Frances Wagner, Responsible Person. 03/17/2021 Contact – Telephone from Ms. Bouck asking to close her licensee 03/18/2021 Exit Conference conducted by telephone with Ms. Bouck, licensee. ALLEGATION: There is yelling and swearing in front of residents. INVESTIGATION: On 01/04/2021, I received a complaint from our Lansing office. The Allegations read as follows: “Country Acres AFC homes has 5 residents that are vulnerable adults. Fran Wagner, she removes the light bulbs at night as she states the residents stay up too late. Fran yells and swears in front of residents.” Upon interviewing Ms. Bouck on 01/05/2021, she explained that relationship between her and Ms. Frances Wagner had significantly deteriorated to the point that their conversations had become less than civil and included Ms. Wagner yelling, and swearing at her in front of residents. It is noted that Ms. Wagner is the property owner and designated “responsible person” of this facility and resides with her husband on the lower level. On 01/04/2021 I received a telephone call from Danial Wagner, who explained that he had received a phone call from his wife, Ms. Bouck who informed him that the home’s owner (Fran Wagner), was yelling, swearing and verbally abusing Ms. Bouck in front of residents and he requested that I go to the home. I told him I could not go and if he thought that residents were in danger of any kind, he should call the police. On 01/05/2021, I spoke by telephone with Ms. Bouck and she explained that Ms. Wagner had come to the home after she had learned that Ms. Bouck was planning to leave the AFC home and seek other employment. She said Ms. Wagner “freaked 5 out,” and started yelling and swearing at her in the kitchen while residents were in the living room. She reported that Ms. Wagner became loud and was verbally abusive to her and called her a “little bitch and a liar.” Ms. Bouck acknowledged that she became upset and told Ms. Wagner; “Your shit needs to end. I’m done with this.” Ms. Bouck stated she called her husband who told her to call the police. Ms. Bouck stated that the police were called, and the Kent County Sheriff’s office sent an officer to the home. Ms. Bouck explained that the officer talked to her alone and to Ms. Wagner alone and he advised them to stay away from each other. Ms. Bouck said that the residents in the living room would not be able to reliably report about the incident due to their disabilities, but that Resident B was sitting in the living room crying while the argument was going on. On 01/05/2021, I conducted a telephone interview with Mr. Wagner, and he confirmed that he heard part of the verbal exchange between the two women. He said he heard Ms. Wagner used the words, “bitch and liar,” towards Ms. Bouck. He said he went to the home and observed that the residents were in the living room. On 01/05/2021, I conducted a telephone interview with Ms.