STATE OF MICHIGAN GRETCHEN WHITMER DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS ORLENE HAWKS GOVERNOR DIRECTOR LANSING

August 28, 2019

Timothy Adams Braintree Management, Inc. 7280 Belding Rd. NE Rockford, MI 49341

RE: License #: AL700338344 Investigation #: 2019A0357026 St. James's Gate

Dear Mr. Adams:

Attached is the Special Investigation Report for the above referenced facility. Due to the violations identified in the report, a written corrective action plan is required. The corrective action plan is due 15 days from the date of this letter and must include the following:  How compliance with each rule will be achieved.  Who is directly responsible for implementing the corrective action for each violation.  Specific time frames for each violation as to when the correction will be completed or implemented.  How continuing compliance will be maintained once compliance is achieved.  The signature of the responsible party and a date.

If you desire technical assistance in addressing these issues, please contact me. In any event, the corrective action plan is due within 15 days. Failure to submit an acceptable corrective action plan will result in disciplinary action.

611 W. OTTAWA  P.O. BOX 30664  LANSING, MICHIGAN 48909 www.michigan.gov/lara  517-335-1980 Please review the enclosed documentation for accuracy and contact me with any questions. In the event that I am not available, and you need to speak to someone immediately, please contact the local office at (616) 356-0101.

Sincerely,

Arlene B. Smith, 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

I. IDENTIFYING INFORMATION

License #: AL700338344

Investigation #: 2019A0357026

Complaint Receipt Date: 07/22/2019

Investigation Initiation Date: 07/22/2019

Report Due Date: 08/21/2019

Licensee Name: Braintree Management, Inc.

Licensee Address: 7280 Belding Rd. NE Rockford, MI 49341

Licensee Telephone #: (616) 874-1573

Administrator: Jessica Adams

Licensee Designee: Timothy Adams

Name of Facility: St. James's Gate

Facility Address: 12844 Renwood Dr. Holland, MI 49424

Facility Telephone #: (616) 399-0071

Original Issuance Date: 09/06/2013

License Status: REGULAR

Effective Date: 02/20/2018

Expiration Date: 02/19/2020

Capacity: 15

Program Type: DEVELOPMENTALLY DISABLED MENTALLY ILL, AGED

1 II. ALLEGATION(S) Violation Established? On 07/20/19 the home was inadequately staffed with 16 to 18 No residents and only one staff person present. Some of Resident A’s medications were outdated, such as cough Yes syrup dated 2014. The home was infested with fleas and/or bed bugs. Yes Raw hamburger left on the counter w/flies on it. Yes The home is filthy and smells. Yes It has been extremely hot, over 90 degrees, and the home was No very hot. Additional Findings Yes

III. METHODOLOGY

07/22/2019 Special Investigation Intake 2019A0357026

07/22/2019 Special Investigation Initiated - Telephone I telephoned a witness and left a message for her to call me.

07/22/2019 Contact -Telephone Call Received From Witness 1.

07/24/2019 Contact Document received From Witness 1. Pictures of her ankles.

08/01/2019 Contact - Face to Face Megan Aukerman, Licensing Consultant and I conducted a face- to-face interview with Resident A at Ottawa County Community Mental Health.

08/01/2019 Contact - Face to Face Witness 1, at Ottawa County CMH and she provided a bag of Resident A's medications that she reported were expired.

08/01/2019 Inspection Completed On-site Ms. Aukerman and I were at the licensed facility where we met and interviewed the facility manager Tommie Moss.

08/01/2019 Contact – Reviewed documents. We reviewed files in the home, including Resident A's MAR, menus, names of staff, and the Resident Register.

2 08/01/2019 Contact - Document Received I received menus, a staff schedule, Resident Register, a copy of St James's Gate list of the first names of the staff and their telephone numbers, Resident A's Health Care Appraisal, Assessment Plan and Resident Care Agreement.

08/01/2019 Contact - Face to Face Licensing Consultant, Megan Aukerman conducted face-to-face interviews with Resident A, B, C, D, E, F, G and H.

08/01/2019 Contact - Face to Face I conducted an interview with Resident I

08/01/2019 Contact - Face to Face Licensing Consultant, Megan Aukerman and I conducted a face- to-face interview with Ms. Tommie Moss, the facility manager. She provided copies of records that we had requested.

08/05/2019 Contact - Telephone call made I telephoned Timothy Adams the Licensee. He provided Jessica Adam’s telephone number

08/07/2019 Contact - Document Received Received and reviewed packets for Resident A, B, C, D, E, F, G, and H. Packets included Health Care Appraisal, Resident Care Agreement and Assessment Plans.

08/07/2019 Contact - Document Received Ms. Jessie Adams

08/07/2019 Contact - Telephone call made I conducted a telephone interview with Direct Care Staff, Tara Straderman, and Melissa Needham, who lives in the AFC home.

08/08/2019 Contact - Document Received Jessica Adams, the Administrator, faxed me the weight records of 14 residents.

08/08/2019 Contact - Document Sent Ms. Adams and I exchanged test messages and I requested the weight record of Resident A. and the physical for Michael/Member of the household.

08/12/2019 Contact -Telephone call received From Witness 2.

3 08/12/2019 Contact – telephone call received From Witness 4.

08/12/2019 Contact – Telephone call received From Witness 3.

08/20/2019 Inspection completed on-site. Conducted an unannounced inspection at the facility.

08/20-21/2019 Exit conference conducted with the Administrator, Jessica Adams by telephone.

ALLEGATION: On 07/20/19 the home was inadequately staffed with 16 to 18 residents and only one staff person present.

INVESTIGATION: On 08/01/2019 we interviewed the Home Manager; Tommie Moss who stated they only have 14 residents and I reviewed the Resident Register and confirmed there are only 14 residents in the facility.

On 08/09/2019, I reviewed the Original Licensing Study Report dated 09/06/2013, and the document stated that the facility can accommodate fifteen (15) residents. Therefore, they were not found to be over their licensed capacity.

On 08/20/2019, I conducted a telephone exit conference with the Administrator, Jessica Adams and she agreed with my findings.

APPLICABLE RULE R 400.15105 Licensed capacity.

(1) The number of residents cared for in a home and the number of resident beds shall not be more than the capacity that is authorized by the home.

ANALYSIS: Ms. Moss, the Home Manager reported they have 14 current residents.

The Resident Register was reviewed, and 14 resident names were recorded.

The Original Licensing Study report indicated they can accommodate 15 residents.

Based on the investigative findings, the home was found to be in compliance with the above rule.

CONCLUSION: VIOLATION NOT ESTABLISHED

4 ALLEGATION: Some of Resident A’s medications were outdated, such as cough syrup dated 2014.

INVESTIGATION: On 07/22/2019, our office received a complaint from BCAL Online Complaints. The complaint read that on 07/20/2019, when picking up Resident A’s medications from the home, it was noted that some were out-of-date by years, such as cough syrup dated 2014.

On 07/22/2019, I received a telephone call from Witness 1. She explained that Resident A was moving out of Saint James’s Gate on 07/20/2019. Witness 1 stated that when it came time to leave, they