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IN THE SUPERIOR COURT OF DEKALB COUNTY
STATE OF GEORGIA
THEODORE SMOTHERS, §
INDIVIDUALLY §
AND ON BEHALF OF THE ESTATE OF §
ANNIE JONES, §
§
Plaintiff, § CIVIL ACTION NO.
§
v. §
§
ATLANTA GA OPCO LLC d/b/a §
BUCKHEAD CENTER FOR NURSING §
& HEALING; GA 2 HOLDCO LLC; §
ENSH CONSULTING LLC; EMPIRE §
CARE CENTERS LLC; GLENWOOD §
HEALTH CENTER BY HARBORVIEW §
LLC d/b/a GLENWOOD HEALTH §
CENTER BY HARBORVIEW; GA NC §
14 HOLDINGS LLC; HARBORVIEW §
HEALTH SYSTEMS INC; THOMAS §
MARTENS; JOHN DOES (1-5) and ABC §
CORPORATIONS (1-5), §
§
Defendants. §
COMPLAINT FOR DAMAGES
THEODORE SMOTHERS, INDIVIDUALLY AND ON BEHALF OF THE ESTATE OF
ANNIE JONES, by his attorneys of record Smith Clinesmith, LLP, Jacob Runyon, Georgia Bar
No. 528373 and Joy Thornton, Georgia Bar No. 865534, 325 N. St. Paul St., 29th Floor, Dallas,
TX 75201, T: 214-953-1900, for Plaintiff.
COMES NOW THEODORE SMOTHERS, INDIVIDUALLY AND ON BEHALF OF
THE ESTATE OF ANNIE JONES, by and through the undersigned counsel, and files this
Complaint against Defendants ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR
COMPLAINT Page 1
NURSING & HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING LLC; EMPIRE CARE
CENTERS LLC; GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a
GLENWOOD HEALTH CENTER BY HARBORVIEW; GA NC 14 HOLDINGS LLC;
HARBORVIEW HEALTH SYSTEMS INC; THOMAS MARTENS, John Does (1-5) and ABC
Corporations (1-5), and alleges as follows:
PRELIMINARY, VENUE, AND JURISDICTION ALLEGATIONS
1. Plaintiff THEODORE SMOTHERS, the natural son of ANNIE JONES, brings this action
individually and as representative of the Estate of ANNIE JONES, for which he intends to
petition the probate court to issue Letters of Administration for THEODORE SMOTHERS
as the Representative of the Estate of ANNIE JONES. THEODORE SMOTHERS is
entitled to prosecute claims for damages on behalf of ANNIE JONES’S estate pursuant to
O.C.G.A. § 51-4-5(b) and O.C.G.A. § 31-8-126(a).
2. THEODORE SMOTHERS is the son of ANNIE JONES and is entitled to prosecute claims
for the full value of ANNIE JONES’S life because of her wrongful death pursuant to
O.C.G.A. § 51-4-2(a).
3. Separate Defendant ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR
NURSING & HEALING is a domestic limited liability company operating a facility
located at 54 Peachtree Park Dr. NE, with its principal office address at 311 Boulevard of
the Americas, Suite 405, Lakewood, NJ 08701. The Defendant’s agent for service of
process is Dede Nichols located at 5437 Bowman Road #416, Macon, GA 31210 or
wherever she may be found. ATLANTA GA OPCO LLC D/B/A BUCKHEAD CENTER
FOR NURSING & HEALING was, and remains, a company engaged in the custodial care
of patients including elderly, helpless individuals who are chronically infirmed, mentally
COMPLAINT Page 2
impaired, and/or in need of medical care and treatment at its facility.
4. Separate Defendant GA 2 HOLDCO LLC is a domestic limited liability company operating
a facility located at 54 Peachtree Park Dr. NE, with its principal office address located at
311 Boulevard of the Americas, Suite 405, Lakewood, NJ, 08701. The Defendant’s agent
for service of process is Dede Nichols located at 5437 Bowman Road #416, Macon, GA
31210 or wherever she may be found. GA 2 HOLDCO LLC was, and remains, a company
engaged in the custodial care of patients including elderly, helpless individuals who are
chronically infirmed, mentally impaired, and/or in need of medical care and treatment at
its facility.
5. Separate Defendant ENSH CONSULTING LLC is a domestic limited liability company
operating a facility located at 54 Peachtree Park Dr. NE, with its principal office address
located at 311 Boulevard of the Americas, Suite 405, Lakewood, NJ 08701. The
Defendant’s agent for service of process is DeDe Goodwin Nichols located at 5437
Bowman Road #416, Macon, GA 31210 or wherever she may be found. ENSH
CONSULTING LLC was, and remains, a company engaged in the custodial care of
patients including elderly, helpless individuals who are chronically infirmed, mentally
impaired, and/or in need of medical care and treatment at its facility.
6. Separate Defendant EMPIRE CARE CENTERS LLC is a foreign limited liability company
operating a facility located at 54 Peachtree Park Dr. NE, with its principal office address
located at 311 Boulevard of the Americas, Suite 405, Lakewood, NJ 08701. The
Defendant’s agent for service of process is Registered Agent Solutions, Inc located at 900
Old Roswell Lakes Pkwy., Suite 310, Roswell, GA 30076 or wherever it may be found.
COMPLAINT Page 3
EMPIRE CARE CENTERS LLC was, and remains, a company engaged in the custodial
care of patients including elderly, helpless individuals who are chronically infirmed,
mentally impaired, and/or in need of medical care and treatment at its facility.
7. Separate Defendant GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a
GLENWOOD HEALTH CENTER BY HARBORVIEW is a foreign limited liability
company operating a facility located at 4115 Glenwood Road, Decatur, GA 30032 with its
principal office address located at 548 Cedarwood Drive, Cedarhurst, NY 11516. The
Defendant’s agent for service of process is Hank Pittman located at Hall Booth Smith, PC
1564 King Road, Tifton, GA 31793 or wherever he may be found. GLENWOOD
HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER
BY HARBORVIEW was, and remains, a company engaged in the custodial care of patients
including elderly, helpless individuals who are chronically infirmed, mentally impaired,
and/or in need of medical care and treatment at its facility.
8. Separate Defendant GA NC 14 HOLDINGS LLC is a foreign limited liability company
incorporated in the state of Delaware and operating a facility located at 4115 Glenwood
Road, Decatur, GA 30032. The Defendant’s agent for service of process is VCORP
Services LLC located at 1013 Centre Road, Suite 403-B, Wilmington, DE 19805 or
wherever it may be found. GA NC 14 HOLDINGS LLC was, and remains, a company
engaged in the custodial care of patients including elderly, helpless individuals who are
chronically infirmed, mentally impaired, and/or in need of medical care and treatment at
its facility.
9. Separate Defendant HARBORVIEW HEALTH SYSTEMS INC is a foreign business
COMPLAINT Page 4
corporation incorporated in the state of New York and operating a facility located at 4115
Glenwood Road, Decatur, GA 30032. The Defendant’s agent for service of process is The
Corporation located at 163 Harborview North, Lawrence, NY 11559 or wherever it may
be found. HARBORVIEW HEALTH SYSTEMS INC was, and remains, a company
engaged in the custodial care of patients including elderly, helpless individuals who are
chronically infirmed, mentally impaired, and/or in need of medical care and treatment at
its facility.
10. Separate Defendant THOMAS MARTENS, Administrator for Glenwood Health Center by
Harborview, may be served with process of service at 4115 Glenwood Road, Decatur, GA
30032 or wherever he may be found.
11. The true names or capacities of Defendants named herein as John Does (1-5) and ABC
Corporations (1-5) are unknown to the Plaintiff, who therefore sues said Defendants by
such fictitious names. Plaintiff will amend the Complaint to show said John Does and ABC
Corporations’ true names when the same have been ascertained. Plaintiff alleges on
information and belief that all John Does and ABC Corporations were negligent as
described in detail below and in Exhibit 1 attached hereto. Plaintiff also alleges that John
Does were employees, actual agents, or apparent agents of ATLANTA GA OPCO LLC
d/b/a BUCKHEAD CENTER FOR NURSING & HEALING and GLENWOOD HEALTH
CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY
HARBORVIEW at all times relevant to this Complaint and were acting incident to and
within the course and scope of their employment or agency with ATLANTA GA OPCO
LLC d/b/a BUCKHEAD CENTER FOR NURSING & HEALING and GLENWOOD
HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER
COMPLAINT Page 5
BY HARBORVIEW at all times relevant to this Complaint, and that John Does were
responsible as medical doctors, medical directors, registered nurses, physician assistants,
licensed practical nurses, or staff for the care and treatment of ANNIE JONES at all times
relevant to this Complaint. Plaintiff also alleges that ABC Corporations were owners,
operators or managers of ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR
NURSING & HEALING and GLENWOOD HEALTH CENTER BY HARBORVIEW
LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW and were responsible
for the care and treatment of ANNIE JONES at all times relevant to this Complaint.
12. Defendants, ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR NURSING
& HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING LLC; EMPIRE CARE
CENTERS LLC; GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a
GLENWOOD HEALTH CENTER BY HARBORVIEW; GA NC 14 HOLDINGS LLC;
HARBORVIEW HEALTH SYSTEMS INC; THOMAS MARTENS, John Does (1-5) and
ABC Corporations (1-5), are subject to the venue and jurisdiction of this Honorable Court,
and are, for purposes of this action, considered to be joint tortfeasors for purposes of venue
and were engaged in a for-profit joint venture to purportedly provide services and care to
patients including elderly and infirm population in Georgia.
13. At all times material hereto, ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER
FOR NURSING & HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING LLC;
EMPIRE CARE CENTERS LLC; GLENWOOD HEALTH CENTER BY
HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW; GA
NC 14 HOLDINGS LLC; HARBORVIEW HEALTH SYSTEMS INC; THOMAS
MARTENS, John Does (1-5) and ABC Corporations (1-5), were engaged in the business
of owning, operating, and/or managing the facility known as BUCKHEAD CENTER FOR
COMPLAINT Page 6
NURSING & HEALING and GLENWOOD HEALTH CENTER BY HARBORVIEW,
and were responsible to the patients of its facility, including ANNIE JONES, for the
provision of her medical and custodial care and treatment, and the provision of skilled
nursing services, including, but not limited to, the provisions of patients' rights.
14. The duties Defendants, ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR
NURSING & HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING LLC; EMPIRE
CARE CENTERS LLC; GLENWOOD HEALTH CENTER BY HARBORVIEW LLC
d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW; GA NC 14 HOLDINGS
LLC; HARBORVIEW HEALTH SYSTEMS INC; THOMAS MARTENS, John Does (1-
5) and ABC Corporations (1-5), owed to ANNIE JONES while she was a resident at their
facility included the duty to provide her with that degree of care, skill, and diligence usually
exhibited by skilled nursing facilities generally in the community, and the duties set forth
in Bill of Rights for Patients of Long-Term Care Facilities as set forth in O.C.G.A. §§ 31-
8-104 through 31-8-121.
15. Pursuant to O.C.G.A. § 9-11-9.1(a), attached hereto, and incorporated herein as Exhibit
“1”, is the Affidavit of a physician affidavit of merit, who qualifies as an expert witness on
the issues raised in this Complaint. The Affidavit specifies at least one negligent act or
omission on the part of Defendants, ATLANTA GA OPCO LLC d/b/a BUCKHEAD
CENTER FOR NURSING & HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING
LLC; EMPIRE CARE CENTERS LLC; GLENWOOD HEALTH CENTER BY
HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW; GA
NC 14 HOLDINGS LLC; HARBORVIEW HEALTH SYSTEMS INC; THOMAS
MARTENS, John Does (1-5) and ABC Corporations (1-5), and/or their staff, and the
factual basis for such negligent act or omission that caused injury to ANNIE JONES. The
COMPLAINT Page 7
Affidavit is not inclusive of each act, error, or omission that has been committed, or may
have been committed by the Defendants and Plaintiffs reserve the right to contend and
prove additional acts, errors, and omissions on the part of Defendants that reflect a
departure from the requisite standard of care required by law.
16. Whenever the term “Defendants” is utilized within this suit, such term collectively refers
to and includes all named Defendants in this lawsuit and all Doe Defendants.
17. Whenever the term “Nursing Home Defendants” is utilized within this suit, such term
collectively refers to and includes ATLANTA GA OPCO LLC d/b/a BUCKHEAD
CENTER FOR NURSING & HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING
LLC; EMPIRE CARE CENTERS LLC; GLENWOOD HEALTH CENTER BY
HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW; GA
NC 14 HOLDINGS LLC; HARBORVIEW HEALTH SYSTEMS INC; THOMAS
MARTENS and ABC Corporations (1-5).
18. Whenever the term “Administrator Defendant” is utilized within this suit, such term refers
to THOMAS MARTENS, who was a managing agent of GLENWOOD HEALTH
CENTER BY HARBORVIEW as alleged herein.
19. Defendants ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR NURSING
& HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING LLC; EMPIRE CARE
CENTERS LLC; GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a
GLENWOOD HEALTH CENTER BY HARBORVIEW; GA NC 14 HOLDINGS LLC;
HARBORVIEW HEALTH SYSTEMS INC; THOMAS MARTENS, John Does (1-5) and
ABC Corporations (1-5), own, operate, manage, and/or control hospitals throughout
Georgia including, but not limited to, Dekalb County. All corporate Defendants have
regular and continuous business in Dekalb County. Defendants were, and remain, owners
COMPLAINT Page 8
and/or managers of an institution, residence or place which is advertised, offered,
maintained or operated for the express or implied purpose of providing accommodations
and care, for a period of more than twenty-four hours, for four or more persons who are ill
or otherwise incapacitated and in need of extensive, ongoing nursing care due to physical
or mental impairment or which provides services for the rehabilitation of persons who are
convalescing from illness or incapacitation in Dekalb County.
20. Jurisdiction is proper in Dekalb County Superior Court as the majority of acts and/or
omissions occurred in Dekalb County and the amount in controversy, exclusive of interest
and costs, far exceeds the minimum jurisdictional limits of this Court.
FACTS
21. On or about October 17, 2022, ANNIE JONES was initially admitted to BUCKHEAD
CENTER FOR NURSING & HEALING (“BUCKHEAD CENTER”). At the time of her
admission, she had a medical history that included: Parkinsons’ disease, type 2 diabetes
mellitus without complications, muscle weakness, dysphagia, abnormalities of gait and
mobility, need for assistance with personal care, gastro-esophageal reflux disease without
esophagitis, anemia, mild protein-calorie malnutrition, anxiety disorder and hypertension.
22. On or about October 21, 2022, Ms. Jones was noted to be at risk of developing pressure
ulcers but did not have any at the time of the assessment. The same assessment did not
have any interventions for skin and ulcer/injury prevention including no turning and
repositioning program.
23. On or about November 17, 2022, Ms. Jones was discharged home from BUCKHEAD
CENTER.
24. On or about November 21, 2022, Ms. Jones was taken to Concentra Urgent care by her
son. Concentra noted that when she was discharged from BUCKHEAD CENTER her son
COMPLAINT Page 9
noted bedsores and a 20lb weight loss. He brought her to the local ER when she was
discharged and was sent home with Keflex. He brought her to Concentra for pain
management. Concentra noted that Ms. Jones had a stage 1 pressure injury to her right
buttock.
25. On or about February 22, 2023, Ms. Jones was admitted to GLENWOOD HEALTH
CENTER BY HARBORVIEW (“GLENWOOD HEALTH CENTER”). At the time of her
admission, she had a medical history that included: hypertension, type 2 diabetes mellitus
without complications, unspecified psychosis, Parkinson’s disease, disturbances of
salivary secretion and urinary tract infection.
26. On or about February 23, 2022, a skin/wound progress note stated that Ms. Jones had no
open areas but did indicate that an old scar area to the sacrum was observed and that it
appeared to be “very fragile.”
27. By on or about March 21, 2023, Ms. Jones was noted to have an open area to her left
buttock. The site measured 2.5 x 2.5 x 0.2 cm.
28. On or about April 5, 2023, Ms. Jones was noted to have an excoriated area that was open
to the sacrum and left buttock. Combined, the sites measured 3.5 cm x 5 cm. At this time,
she was also noted to have a poor appetite, incontinence and a very thin frame.
29. On or about June 30, 2023, a Braden Scale assessment found Ms. Jones to be an “8” on the
scale-putting her at “very high risk” of developing pressure ulcers.
30. On or about July 2, 2023, Ms. Jones’s skin assessment showed healed wounds to the
buttock and sacrum. Not long after, on or about July 17, 2023, Ms. Jones had a wound to
her sacrum and buttocks measuring 7 cm x 10.5 cm due to moisture associated skin
damage.
COMPLAINT Page 10
31. On or about July 22, 2023, a skin assessment revealed an unstageable wound to the left
buttock and sacral area measuring 7.5 cm x 5 cm x 0.1 cm with “scattered necrosis.”
32. On or about September 7, 2023, Ms. Jones was noted to have a stage III pressure ulcer to
her sacrum measuring 5 cm x 7.0.1 cm.
33. On or about September 14, 2023, Ms. Jones was discharged from GLENWOOD HEALTH
CENTER and moved to Fort Valley Nursing Home.
34. On or about September 19, 2023, Ms. Jones passed away. On the death certificate, her
causes of death were listed as follows: pneumonia, malnutrition, diabetes myelitis and
hypertension.
35. As skilled nursing facilities, the standard of care for BUCKHEAD CENTER and
GLENWOOD HEALTH CENTER required that they provide care and treatment at a level
that a reasonable, prudent similar facility and staff would provide under the same or similar
circumstances. BUCKHEAD CENTER and GLENWOOD HEALTH CENTER, and their
managers and operators, and nursing staff breached the standard of care in several ways.
36. Ms. Jones was at severe risk for pressure wound development. The standard of care was
breached in that she did not receive every 2-hour turning and repositioning. Ms. Jones was
incontinent of bladder and bowel. Nursing staff were required to place her on a 2-hour
toileting schedule to ensure that her peri area was kept dry and to protect her skin from
fragility and breakdown. They failed to do so, resulting in skin breakdown.
37. Management and owners of BUCKHEAD CENTER and GLENWOOD HEALTH
CENTER were required to ensure that their nursing staff were provided with adequate
training to provide care to residents. They were required to provide training and have in
place policies and procedures for nursing staff to follow. They failed to do so.
COMPLAINT Page 11
38. Management and operators of facilities such as BUCKHEAD CENTER and GLENWOOD
HEALTH CENTER are required to ensure that care interventions are in place, that the care
interventions are being followed and that the facility has policies and procedures, as well
as sufficient staff to provide necessary care. To a reasonable degree of medical probability,
this was not done by management and operations staff, thus leading to the injuries
complained of in the care of Ms. Jones.
39. Defendants were well aware of ANNIE JONES'S medical condition and the care that she
required when they represented that they could adequately care for his needs. Defendants
made affirmative representations to the family that the appropriate level of care would be
provided when the Defendants knew, because of budgetary restrictions on staffing and
supplies, that residents, including ANNIE JONES, would not get the necessary care.
40. Defendants held themselves out as being:
a. Skilled in the performance of nursing, rehabilitative, and other medical support
services;
b. Properly staffed, supervised, and equipped to meet the total needs of its nursing
home residents;
c. Providing around the clock skilled nursing care;
d. Able to specifically meet the total nursing home, medical, and physical therapy
needs of ANNIE JONES and other residents like her; and
e. Licensed and complying on a continual basis with all rules, regulations, and
standards established for nursing homes, nursing home licensees, and nursing home
administrators as alleged herein.
COMPLAINT Page 12
41. Defendants failed to discharge their obligations of care to ANNIE JONES. As a
consequence thereof, ANNIE JONES suffered catastrophic injuries, disfigurement,
extreme pain, suffering mental anguish, fright and death. The scope and severity of the
recurrent wrongs inflicted upon ANNIE JONES while under the care of the facility
accelerated the deterioration of her health and physical condition beyond that caused by
the normal aging process and resulted in physical and emotional trauma which includes,
but is not limited to:
a. Pressure wounds;
b. Urinary tract infections;
c. Dehydration and malnutrition;
d. Overmedication and/or incorrect medication monitoring;
e. Poor hygiene and failure to provide for basic needs including but not limited to
toileting, hygiene and mobility. and
f. Death.
42. All of the above identified injuries, as well as the conduct specified herein, caused ANNIE
JONES to lose her personal dignity and extreme and unnecessary pain, degradation,
anguish, otherwise unnecessary hospitalizations, disfigurement, and emotional trauma.
43. The wrongs complained of herein were of a continuing nature and occurred throughout
ANNIE JONES'S residency at Defendants' facility.
44. Defendants were aware of the systemic staffing problems at BUCKHEAD CENTER and
GLENWOOD HEALTH CENTER throughout the residency of ANNIE JONES via
Summary Labor Reports, which were available at all levels of Defendants' corporate
structure, these staffing failures directly impacted the care to the residents, including
ANNIE JONES.
COMPLAINT Page 13
45. Defendants, and each of them, were aware of the systemic problems within BUCKHEAD
CENTER and GLENWOOD HEALTH CENTER relating to resident care, specifically
including numerous falls resulting in significant injury and damage including those alleged
herein by Ms. Jones. These care-based indicators were specifically selected after extensive
research as indicators of the quality of care being provided to the residents, including
ANNIE JONES. These quality indicators were monitored and available to the Defendants
via monthly if not weekly reports.
46. Defendants' upper-level management conducted regular meetings for its different areas of
operations including Georgia. These meetings kept all Defendants informed of the systemic
problems at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER and the other
facilities in Georgia.
47. Plaintiff alleges that on all of the occasions complained of herein, ANNIE JONES was
under the care, supervision, and treatment of the agents and/or employees of Defendants
and that the injuries complained of herein were proximately caused by the acts and
omissions of Defendants named herein.
48. Defendants had vicarious liability for the acts and omissions of all persons or entities under
Defendants' control, either directly or indirectly, including its employees, agents,
consultants, and independent contractors, whether in-house or outside entities, individuals,
agencies, or pools causing or contributing to the injuries of ANNIE JONES.
49. The Defendants are directly liable for the acts and/or omissions contained herein due to the
direct control, ownership, and/or management of the operations of BUCKHEAD CENTER
and GLENWOOD HEALTH CENTER. This exertion of control, ownership, and/or
management by the Defendants created a dangerous environment for all residents,
including ANNIE JONES.
COMPLAINT Page 14
50. The Defendants were aware of the dangerous environment that was created by their
methods of management and/or control at all their facilities, including BUCKHEAD
CENTER and GLENWOOD HEALTH CENTER and the harm caused to the residents,
including ANNIE JONES.
51. This methodology of management and/or control was set out in the Corporate Plan created
and/or implemented by executives of the Nursing Home Defendants.
52. Defendants have joint and several liability for the actions complained of herein because
they consciously and deliberately pursued a common plan or design to commit the tortious
acts described in this Complaint and these Defendants actively took part in such actions.
COUNT ONE
CORPORATE NEGLIGENCE AGAINST NURSING HOME DEFENDANTS, THOMAS
MARTENS, JOHN DOES (1-5) AND ABC CORPORATIONS (1-5)
53. Plaintiff re-alleges and incorporates all of the allegations in the Complaint as if set forth
herein.
54. Nursing Home Defendants owed a duty to residents, including ANNIE JONES, to act in a
manner consistent with the proper operation of the nursing homes they controlled, which a
reasonably careful person/corporation would provide under similar circumstances.
55. Nursing Home Defendants' employees owed a duty to residents, including ANNIE JONES,
to exercise reasonable care in providing oversight and management of the nursing homes
they owned, operated, managed, and/or controlled.
56. Nursing Home Defendants breached this duty by failing to properly manage, operate,
and/or control these nursing homes, including BUCKHEAD CENTER and GLENWOOD
HEALTH CENTER, in a manner that a reasonably careful person/corporation would have
provided under similar circumstances and by failing to properly allocate resources, provide
appropriate policies and procedures, take appropriate corrective action when operational
COMPLAINT Page 15
problems are brought to their attention, intentionally concealing the severity and existence
of these failures from affected residents, and intentionally concealing the severity and
existence of these failures from the State and Federal Government.
57. The negligence of the Nursing Home Defendants, their employees, agents, and consultants,
includes, but is not limited to, one or more of the following acts and omissions:
a. Staffing:
i. Nursing home residents, including ANNIE JONES, often are unable to care
for themselves; thus, they rely on nursing home staff to provide many, if not
all, of their activities of daily living (ADL's). Nursing facilities have a
common law duty, as well as a statutory duty, to have sufficient nursing staff
to provide for the needs of their residents.
ii. The Nursing Home Defendants are responsible and required to provide
sufficient resources to hire and maintain sufficient staff to ensure that these
residents' needs are met.
iii. Additionally, when the Nursing Home Defendants fail to provide sufficient
resources to hire and maintain sufficient staff, the staff who are present are
unable to meet the total needs of the residents through no fault of their own.
iv. When the Nursing Home Defendants fail to provide sufficient resources to
hire and maintain sufficient staff, those who are present must take shortcuts
with respect to all aspects of their job and are unable to do their job.
v. Rather than hiring and maintaining sufficient staff, Separate Defendants
hired too few registered nurses, too few LPNs, and too few certified nursing
assistants. More importantly, too many of these staff members skipped work
or terminated their employment because they did not have enough co-
COMPLAINT Page 16
workers to properly care for the residents who depended upon them, or
because of deplorable working conditions, or because the pay set by these
Corporate Defendants was too low, or such other reasons as will be proven
at trial of this matter.
b. Nursing Home Defendants failed to implement adequate guidelines, policies, and
procedures for:
i. Investigating the relevant facts, underlying deficiencies, or licensure
violations or penalties found to exist at BUCKHEAD CENTER and
GLENWOOD HEALTH CENTER by the Georgia Department of
Community Health or any state or federal survey agency;
ii. Determining the cause of any such deficiencies, violations or penalties;
iii. Correcting deficiencies or licensure violations or penalties found to exist at
BUCKHEAD CENTER and GLENWOOD HEALTH CENTER; and
iv. Notifying residents affected by and those potentially affected by
deficiencies cited by any state or federal survey agency.
c. Nursing Home Defendants failed to adopt adequate guidelines, policies, and
procedures for determining whether BUCKHEAD CENTER and GLENWOOD
HEALTH CENTER had sufficient numbers of nursing personnel to:
i. Provide 24-hour compliance with all contracts, all state statutes, or rules,
and/or all applicable federal statutes or regulations; and
ii. To correct and address any and all failures to comply with all contracts, all
state statutes or rules, and/or all applicable federal statutes or regulations.
d. Nursing Home Defendants failed to adopt adequate guidelines, policies, and
procedures at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER for
COMPLAINT Page 17
documenting, maintaining files, investigating and responding to any complaint
regarding compliance with all contracts, all state statutes or rules, and/or all
applicable federal statutes or regulations by employees at BUCKHEAD CENTER
and GLENWOOD HEALTH CENTER regardless of whether such complaint
derived from a state survey agency, a resident of the facility, an employee of the
facility, or any interested person. This failure resulted in injury, abuse, and neglect
to residents of the facility, including ANNIE JONES.
e. Budgeting or Allocation of Resources:
i. Nursing Home Defendants were responsible for providing accurate
information regarding the monetary needs of the facility so that a workable
budget could be set.
ii. Nursing Home Defendants were required to administer BUCKHEAD
CENTER and GLENWOOD HEALTH CENTER in a manner that enabled
it to use resources effectively and efficiently to comply with all contracts,
all state statutes or rules, and/or all applicable federal statutes or regulations.
iii. Nursing Home Defendants were responsible for allocating funds within the
budget in a manner that ensured compliance with all contracts, all state
statutes or rules, and/or all applicable federal statutes or regulations.
iv. Nursing Home Defendants failed to properly allocate the budgetary needs
of the facility and to properly allocate the funds budgeted to the facility for
compliance with all contracts, all state statutes or rules, and/or all applicable
federal statutes or regulations, resulting in the following:
COMPLAINT Page 18
1. Staffing levels that were insufficient to comply with all contracts, all
state statutes or rules, and/or all applicable federal statutes or
regulations for each resident, including ANNIE JONES.
2. Supplies and food were insufficient to comply with all contracts, all
state statutes or rules, and/or all applicable federal statutes or
regulations for each resident, including ANNIE JONES.
3. Upon information and belief, Plaintiff alleges that rather than
properly allocating the budgeted funds, Nursing Home Defendants
inappropriately allocated or allowed funds to be paid to management
companies that did not assist or even participate in managing the
care provided to the residents. Rather, Nursing Home Defendants
only enhanced the profits of the home, allocated funds to employees
whose only duties were non-patient oriented, and to items and
services that were unnecessary to achieve the proper goal of
compliance with all contracts, all state statutes or rules, and/or all
applicable federal statutes or regulations.
v. The failure to adequately budget and allocate resources to the facility
directly caused damages to ANNIE JONES.
f. Corporate Compliance and Reporting.
i. Nursing Home Defendants were responsible for ensuring that the facility
complied with state and federal standards as to the residents of the home.
To that end, they were required to file various reports with regulatory
entities.
COMPLAINT Page 19
ii. Nursing Home Defendants were charged with the responsibility of reporting
instances of noncompliance with all contracts, all state statutes or rules,
and/or all applicable federal statutes or regulations that occurred at the
facility. Upon information and belief, Plaintiff alleges that their failure to
properly and timely do so resulted in additional injuries to residents,
including ANNIE JONES.
iii. Upon information and belief, Plaintiff alleges that Nursing Home
Defendants failed to properly recognize and report instances of non-
compliance occurring at BUCKHEAD CENTER and GLENWOOD
HEALTH CENTER, and further failed to correct those instances. These
failures to report resulted in the appearance of a facility that was properly
managed and maintained. This false and misleading appearance induced the
family of BUCKHEAD CENTER and GLENWOOD HEALTH CENTER
to place her in the facility and misled them as to the facility's compliance
with all contracts, all state statutes or rules, and/or all applicable federal
statutes or regulations. Further, upon information and belief, Plaintiff
alleges that because certain problems were not reported or were under-
reported, the facility escaped inspections and investigations by regulatory
agencies and even in-house reviews that might have corrected the
deficiencies. These deficiencies that the facility experienced created a more
dangerous environment in which additional injuries could occur to
residents, including ANNIE JONES.
iv. Corporate Defendants were responsible for ensuring that no claims for
reimbursement were submitted to the federal or state governments for
COMPLAINT Page 20
services that were not provided, or services provided that did not comply
with all contracts, all state statutes or rules, and/or all applicable federal
statutes or regulations. Upon information and belief, Corporate Defendants
submitted inaccurate claims as a result of the various staffing issues listed
above, resulting in unjust enrichment to the facility.
v. The failure to adequately comply with and report violations of state and
federal standards directly caused harm to ANNIE JONES.
58. A reasonably careful Corporation, operating under similar circumstances, would foresee
that the failure to provide the appropriate oversight, management, direction, and/or control
would result in poorly operated nursing homes such as BUCKHEAD CENTER and
GLENWOOD HEALTH CENTER and devastating injuries to residents including ANNIE
JONES.
59. As a direct and proximate result of the negligence of Nursing Home Defendants as set out
above, ANNIE JONES suffered injuries, including pressure sores, infections, and also
suffered extreme pain, suffering, mental anguish, embarrassment, fright and death, all of
which required hospitalization and medical treatment, and required ANNIE JONES to
incur significant hospital and medical expenses.
60. WHEREFORE, based on such conduct of Nursing Home Defendants as set forth above,
Plaintiff asserts a claim for judgment for all compensatory damages and punitive damages
against Nursing Home Defendants including, but not limited to, medical expenses, physical
pain, suffering, mental anguish, disability, loss of enjoyment of life, humiliation,
disfigurement, fright and death in an amount to be determined by the jury, plus costs and
all other relief to which Plaintiff is entitled by law.
COMPLAINT Page 21
COUNT TWO
NEGLIGENCE CLAIM AGAINST ADMINISTRATOR DEFENDANTS AND JOHN
DOES (1 -5)
61. Plaintiff re-alleges and incorporates all of the allegations in the Complaint as if set forth
herein.
62. Upon information and belief, Administrator Defendant and John Does (1-5), were the
administrators of BUCKHEAD CENTER and GLENWOOD HEALTH CENTER during
the residency of ANNIE JONES. To the extent the names of the licensed administrators
who may have managed this facility during the residency of ANNIE JONES are
determined, all of the following acts are properly attributed to them, and Plaintiff will seek
leave to substitute these individuals as proper party Defendants.
63. As nursing home administrators, Administrator Defendants owed a common law duty to
act as reasonably prudent nursing home administrators and to prevent all reasonably
foreseeable injuries to the residents of BUCKHEAD CENTER and GLENWOOD
HEALTH CENTER.
64. As nursing home administrators, Administrator Defendants owed a common law duty to
remain informed as to events occurring at BUCKHEAD CENTER and GLENWOOD
HEALTH CENTER through contact with the various departments that they managed,
including, but not limited to, nursing, dietary, therapy, housekeeping, social services, and
maintenance. Administrator Defendants were required under law to be aware of matters
occurring at the nursing home and to take affirmative steps to correct problems, particularly
when those problems could reasonably cause or contribute to an injury, abuse, or neglect
to residents of the home.
COMPLAINT Page 22
65. When Administrator Defendants accepted the position of administrator of BUCKHEAD
CENTER and GLENWOOD HEALTH CENTER, they assumed the duties as set forth in
the preceding paragraphs.
66. It is reasonably foreseeable that injuries, abuse, and neglect to residents of BUCKHEAD
CENTER and GLENWOOD HEALTH CENTER, including ANNIE JONES, would occur
as a direct result of Administrator Defendants' failures to carry out their duties as
administrators of the facility.
67. As nursing home administrators, Administrator Defendants were centrally involved and
actively participated in tortious conduct that directly caused or contributed to the injuries
of ANNIE JONES. The following areas describe with specificity the wrongdoings of
Administrator Defendants that resulted in harm to ANNIE JONES:
a. Staffing:
i. Nursing home residents, including ANNIE JONES, often are unable to care
for themselves; thus, they rely on nursing home staff to provide many, if not
all, of their activities of daily living. Nursing facilities have a common law
duty, as well as a statutory duty, to have sufficient nursing staff to provide
for the needs of their residents.
ii. The administrator is responsible and required to hire and maintain sufficient
staff to ensure that these residents' needs are met. Further, the administrator
must establish and maintain proper working relationships with physicians,
nurse practitioners, and employees of the facility.
iii. When the administrator, as here, fails to hire and maintain sufficient staff
and fails to maintain proper working relationships between the departments
of the facility, the residents do not receive adequate and appropriate care.
COMPLAINT Page 23
iv. Additionally, when the administrator fails to hire and maintain sufficient
staff, the staff who are present are unable to meet the total needs of the
residents through no fault of their own.
v. When the administrator fails to hire and maintain sufficient staff, those who
are present must take shortcuts with respect to the care provided and are
unable to provide adequate and appropriate care to the residents of the
facility.
vi. Rather than hiring and maintaining sufficient staff, Administrator
Defendants hired too few registered nurses, too few LPNs, and too few
certified nurse assistants. More importantly, too many of these staff
members skipped work or terminated their employment because they did
not have enough co-workers to properly care for the residents who depended
upon them, or because of deplorable working conditions, or because the pay
set by the nursing home with the input of the administrator was too low, or
such other reasons as will be proven at trial of this matter.
vii. Administrator Defendants failed to develop and maintain proper working
relationships between physicians, nurse practitioners and employees of the
facility, and between the various departments they managed. ANNIE
JONES was injured through their failure to manage these individuals and
departments in a way that they could fluidly and seamlessly work together.
viii. Due to staff shortages at BUCKHEAD CENTER and GLENWOOD
HEALTH CENTER, ANNIE JONES'S medical records were not kept and
maintained in accordance with accepted professional standards and
practices. This incomplete documentation resulted in further injuries to
COMPLAINT Page 24
ANNIE JONES-the facility was unable to properly understand her
condition, changes that occurred in her condition, and whether or not her
care plan and dietary assessments were properly modified to address
changes in her condition.
ix. Administrator Defendants owed a non-delegable duty to ANNIE JONES
and other residents of BUCKHEAD CENTER and GLENWOOD HEALTH
CENTER, during their tenure as administrators, to ensure adequate and
appropriate custodial care and supervision through their control over
staffing issues. A reasonably prudent nursing home administrator would
have known or should have known that injuries would occur to residents
such as ANNIE JONES if staffing levels were not maintained within
reasonable parameters.
x. With respect to staffing, the failures of Separate Defendants include but are
not limited to:
1. Ensuring that the staff provided ANNIE JONES adequate hygiene
and sanitary care;
2. Ensuring that the staff provided ANNIE JONES clean bed linens to
prevent urine and fecal contact for extended periods of time;
3. Providing sufficient numbers of qualified personnel, including
nurses, licensed practical nurses, certified nurse assistants, and
medication aides (nursing personnel) to meet the total needs of
ANNIE JONES throughout her residency; and
4. Ensuring that ANNIE JONES:
a. Received timely and accurate care assessments;
COMPLAINT Page 25
b. Received prescribed treatment, medication and diet;
c. Was protected from accidental or intentional injuries by the
correct use of ordered and reasonable safety measures and
proper supervision of staff and other residents;
d. Keeping ANNIE JONES clean and comfortable and to
prevent the formation of bedsores, ulcers and lesions on his
body;
e. Providing a safe environment free from preventable abuse
and neglect;
f. Ensuring that ANNIE JONES received care, treatment, and
medication in accordance with physician's orders; and
g. Ensuring that ANNIE JONES was provided with the dignity
and respect that all nursing home residents are entitled to
receive.
xi. Adequately screen, evaluate and check references, test for competence, and
use ordinary care in selecting nursing personnel to work at BUCKHEAD
CENTER and GLENWOOD HEALTH CENTER;
xii. Terminating employees at BUCKHEAD CENTER and GLENWOOD
HEALTH CENTER that were known (or should have been known) to be
careless, incompetent, and unwilling to comply with the policy and
procedures of the facility and the rules and regulations promulgated and
adopted by the Georgia Division of Health;
COMPLAINT Page 26
xiii. Assigning nursing personnel at BUCKHEAD CENTER and GLENWOOD
HEALTH CENTER consistent with their education and experience and
based on:
1. ANNIE JONES'S medical history and condition, nursing, and
rehabilitative needs;
2. The characteristics of the resident population residing in the area of
the facility where ANNIE JONES was a resident; and
3. Nursing skills needed to provide care for such resident population.
b. Administrator Defendants failed to implement adequate guidelines, policies, and
procedures for:
i. Investigating the relevant facts, underlying deficiencies, or licensure
violations or penalties found to exist at BUCKHEAD CENTER and
GLENWOOD HEALTH CENTER by any state or federal survey agency;
ii. Determining the cause of any such deficiencies, violations, or penalties; and
iii. Correcting deficiencies or licensure violations or penalties found to
Preview
IN THE SUPERIOR COURT OF DEKALB COUNTY STATE OF GEORGIA THEODORE SMOTHERS, § INDIVIDUALLY § AND ON BEHALF OF THE ESTATE OF § ANNIE JONES, § § Plaintiff, § CIVIL ACTION NO. § v. § § ATLANTA GA OPCO LLC d/b/a § BUCKHEAD CENTER FOR NURSING § & HEALING; GA 2 HOLDCO LLC; § ENSH CONSULTING LLC; EMPIRE § CARE CENTERS LLC; GLENWOOD § HEALTH CENTER BY HARBORVIEW § LLC d/b/a GLENWOOD HEALTH § CENTER BY HARBORVIEW; GA NC § 14 HOLDINGS LLC; HARBORVIEW § HEALTH SYSTEMS INC; THOMAS § MARTENS; JOHN DOES (1-5) and ABC § CORPORATIONS (1-5), § § Defendants. § COMPLAINT FOR DAMAGES THEODORE SMOTHERS, INDIVIDUALLY AND ON BEHALF OF THE ESTATE OF ANNIE JONES, by his attorneys of record Smith Clinesmith, LLP, Jacob Runyon, Georgia Bar No. 528373 and Joy Thornton, Georgia Bar No. 865534, 325 N. St. Paul St., 29th Floor, Dallas, TX 75201, T: 214-953-1900, for Plaintiff. COMES NOW THEODORE SMOTHERS, INDIVIDUALLY AND ON BEHALF OF THE ESTATE OF ANNIE JONES, by and through the undersigned counsel, and files this Complaint against Defendants ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR COMPLAINT Page 1 NURSING & HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING LLC; EMPIRE CARE CENTERS LLC; GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW; GA NC 14 HOLDINGS LLC; HARBORVIEW HEALTH SYSTEMS INC; THOMAS MARTENS, John Does (1-5) and ABC Corporations (1-5), and alleges as follows: PRELIMINARY, VENUE, AND JURISDICTION ALLEGATIONS 1. Plaintiff THEODORE SMOTHERS, the natural son of ANNIE JONES, brings this action individually and as representative of the Estate of ANNIE JONES, for which he intends to petition the probate court to issue Letters of Administration for THEODORE SMOTHERS as the Representative of the Estate of ANNIE JONES. THEODORE SMOTHERS is entitled to prosecute claims for damages on behalf of ANNIE JONES’S estate pursuant to O.C.G.A. § 51-4-5(b) and O.C.G.A. § 31-8-126(a). 2. THEODORE SMOTHERS is the son of ANNIE JONES and is entitled to prosecute claims for the full value of ANNIE JONES’S life because of her wrongful death pursuant to O.C.G.A. § 51-4-2(a). 3. Separate Defendant ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR NURSING & HEALING is a domestic limited liability company operating a facility located at 54 Peachtree Park Dr. NE, with its principal office address at 311 Boulevard of the Americas, Suite 405, Lakewood, NJ 08701. The Defendant’s agent for service of process is Dede Nichols located at 5437 Bowman Road #416, Macon, GA 31210 or wherever she may be found. ATLANTA GA OPCO LLC D/B/A BUCKHEAD CENTER FOR NURSING & HEALING was, and remains, a company engaged in the custodial care of patients including elderly, helpless individuals who are chronically infirmed, mentally COMPLAINT Page 2 impaired, and/or in need of medical care and treatment at its facility. 4. Separate Defendant GA 2 HOLDCO LLC is a domestic limited liability company operating a facility located at 54 Peachtree Park Dr. NE, with its principal office address located at 311 Boulevard of the Americas, Suite 405, Lakewood, NJ, 08701. The Defendant’s agent for service of process is Dede Nichols located at 5437 Bowman Road #416, Macon, GA 31210 or wherever she may be found. GA 2 HOLDCO LLC was, and remains, a company engaged in the custodial care of patients including elderly, helpless individuals who are chronically infirmed, mentally impaired, and/or in need of medical care and treatment at its facility. 5. Separate Defendant ENSH CONSULTING LLC is a domestic limited liability company operating a facility located at 54 Peachtree Park Dr. NE, with its principal office address located at 311 Boulevard of the Americas, Suite 405, Lakewood, NJ 08701. The Defendant’s agent for service of process is DeDe Goodwin Nichols located at 5437 Bowman Road #416, Macon, GA 31210 or wherever she may be found. ENSH CONSULTING LLC was, and remains, a company engaged in the custodial care of patients including elderly, helpless individuals who are chronically infirmed, mentally impaired, and/or in need of medical care and treatment at its facility. 6. Separate Defendant EMPIRE CARE CENTERS LLC is a foreign limited liability company operating a facility located at 54 Peachtree Park Dr. NE, with its principal office address located at 311 Boulevard of the Americas, Suite 405, Lakewood, NJ 08701. The Defendant’s agent for service of process is Registered Agent Solutions, Inc located at 900 Old Roswell Lakes Pkwy., Suite 310, Roswell, GA 30076 or wherever it may be found. COMPLAINT Page 3 EMPIRE CARE CENTERS LLC was, and remains, a company engaged in the custodial care of patients including elderly, helpless individuals who are chronically infirmed, mentally impaired, and/or in need of medical care and treatment at its facility. 7. Separate Defendant GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW is a foreign limited liability company operating a facility located at 4115 Glenwood Road, Decatur, GA 30032 with its principal office address located at 548 Cedarwood Drive, Cedarhurst, NY 11516. The Defendant’s agent for service of process is Hank Pittman located at Hall Booth Smith, PC 1564 King Road, Tifton, GA 31793 or wherever he may be found. GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW was, and remains, a company engaged in the custodial care of patients including elderly, helpless individuals who are chronically infirmed, mentally impaired, and/or in need of medical care and treatment at its facility. 8. Separate Defendant GA NC 14 HOLDINGS LLC is a foreign limited liability company incorporated in the state of Delaware and operating a facility located at 4115 Glenwood Road, Decatur, GA 30032. The Defendant’s agent for service of process is VCORP Services LLC located at 1013 Centre Road, Suite 403-B, Wilmington, DE 19805 or wherever it may be found. GA NC 14 HOLDINGS LLC was, and remains, a company engaged in the custodial care of patients including elderly, helpless individuals who are chronically infirmed, mentally impaired, and/or in need of medical care and treatment at its facility. 9. Separate Defendant HARBORVIEW HEALTH SYSTEMS INC is a foreign business COMPLAINT Page 4 corporation incorporated in the state of New York and operating a facility located at 4115 Glenwood Road, Decatur, GA 30032. The Defendant’s agent for service of process is The Corporation located at 163 Harborview North, Lawrence, NY 11559 or wherever it may be found. HARBORVIEW HEALTH SYSTEMS INC was, and remains, a company engaged in the custodial care of patients including elderly, helpless individuals who are chronically infirmed, mentally impaired, and/or in need of medical care and treatment at its facility. 10. Separate Defendant THOMAS MARTENS, Administrator for Glenwood Health Center by Harborview, may be served with process of service at 4115 Glenwood Road, Decatur, GA 30032 or wherever he may be found. 11. The true names or capacities of Defendants named herein as John Does (1-5) and ABC Corporations (1-5) are unknown to the Plaintiff, who therefore sues said Defendants by such fictitious names. Plaintiff will amend the Complaint to show said John Does and ABC Corporations’ true names when the same have been ascertained. Plaintiff alleges on information and belief that all John Does and ABC Corporations were negligent as described in detail below and in Exhibit 1 attached hereto. Plaintiff also alleges that John Does were employees, actual agents, or apparent agents of ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR NURSING & HEALING and GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW at all times relevant to this Complaint and were acting incident to and within the course and scope of their employment or agency with ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR NURSING & HEALING and GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER COMPLAINT Page 5 BY HARBORVIEW at all times relevant to this Complaint, and that John Does were responsible as medical doctors, medical directors, registered nurses, physician assistants, licensed practical nurses, or staff for the care and treatment of ANNIE JONES at all times relevant to this Complaint. Plaintiff also alleges that ABC Corporations were owners, operators or managers of ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR NURSING & HEALING and GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW and were responsible for the care and treatment of ANNIE JONES at all times relevant to this Complaint. 12. Defendants, ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR NURSING & HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING LLC; EMPIRE CARE CENTERS LLC; GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW; GA NC 14 HOLDINGS LLC; HARBORVIEW HEALTH SYSTEMS INC; THOMAS MARTENS, John Does (1-5) and ABC Corporations (1-5), are subject to the venue and jurisdiction of this Honorable Court, and are, for purposes of this action, considered to be joint tortfeasors for purposes of venue and were engaged in a for-profit joint venture to purportedly provide services and care to patients including elderly and infirm population in Georgia. 13. At all times material hereto, ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR NURSING & HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING LLC; EMPIRE CARE CENTERS LLC; GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW; GA NC 14 HOLDINGS LLC; HARBORVIEW HEALTH SYSTEMS INC; THOMAS MARTENS, John Does (1-5) and ABC Corporations (1-5), were engaged in the business of owning, operating, and/or managing the facility known as BUCKHEAD CENTER FOR COMPLAINT Page 6 NURSING & HEALING and GLENWOOD HEALTH CENTER BY HARBORVIEW, and were responsible to the patients of its facility, including ANNIE JONES, for the provision of her medical and custodial care and treatment, and the provision of skilled nursing services, including, but not limited to, the provisions of patients' rights. 14. The duties Defendants, ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR NURSING & HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING LLC; EMPIRE CARE CENTERS LLC; GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW; GA NC 14 HOLDINGS LLC; HARBORVIEW HEALTH SYSTEMS INC; THOMAS MARTENS, John Does (1- 5) and ABC Corporations (1-5), owed to ANNIE JONES while she was a resident at their facility included the duty to provide her with that degree of care, skill, and diligence usually exhibited by skilled nursing facilities generally in the community, and the duties set forth in Bill of Rights for Patients of Long-Term Care Facilities as set forth in O.C.G.A. §§ 31- 8-104 through 31-8-121. 15. Pursuant to O.C.G.A. § 9-11-9.1(a), attached hereto, and incorporated herein as Exhibit “1”, is the Affidavit of a physician affidavit of merit, who qualifies as an expert witness on the issues raised in this Complaint. The Affidavit specifies at least one negligent act or omission on the part of Defendants, ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR NURSING & HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING LLC; EMPIRE CARE CENTERS LLC; GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW; GA NC 14 HOLDINGS LLC; HARBORVIEW HEALTH SYSTEMS INC; THOMAS MARTENS, John Does (1-5) and ABC Corporations (1-5), and/or their staff, and the factual basis for such negligent act or omission that caused injury to ANNIE JONES. The COMPLAINT Page 7 Affidavit is not inclusive of each act, error, or omission that has been committed, or may have been committed by the Defendants and Plaintiffs reserve the right to contend and prove additional acts, errors, and omissions on the part of Defendants that reflect a departure from the requisite standard of care required by law. 16. Whenever the term “Defendants” is utilized within this suit, such term collectively refers to and includes all named Defendants in this lawsuit and all Doe Defendants. 17. Whenever the term “Nursing Home Defendants” is utilized within this suit, such term collectively refers to and includes ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR NURSING & HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING LLC; EMPIRE CARE CENTERS LLC; GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW; GA NC 14 HOLDINGS LLC; HARBORVIEW HEALTH SYSTEMS INC; THOMAS MARTENS and ABC Corporations (1-5). 18. Whenever the term “Administrator Defendant” is utilized within this suit, such term refers to THOMAS MARTENS, who was a managing agent of GLENWOOD HEALTH CENTER BY HARBORVIEW as alleged herein. 19. Defendants ATLANTA GA OPCO LLC d/b/a BUCKHEAD CENTER FOR NURSING & HEALING; GA 2 HOLDCO LLC; ENSH CONSULTING LLC; EMPIRE CARE CENTERS LLC; GLENWOOD HEALTH CENTER BY HARBORVIEW LLC d/b/a GLENWOOD HEALTH CENTER BY HARBORVIEW; GA NC 14 HOLDINGS LLC; HARBORVIEW HEALTH SYSTEMS INC; THOMAS MARTENS, John Does (1-5) and ABC Corporations (1-5), own, operate, manage, and/or control hospitals throughout Georgia including, but not limited to, Dekalb County. All corporate Defendants have regular and continuous business in Dekalb County. Defendants were, and remain, owners COMPLAINT Page 8 and/or managers of an institution, residence or place which is advertised, offered, maintained or operated for the express or implied purpose of providing accommodations and care, for a period of more than twenty-four hours, for four or more persons who are ill or otherwise incapacitated and in need of extensive, ongoing nursing care due to physical or mental impairment or which provides services for the rehabilitation of persons who are convalescing from illness or incapacitation in Dekalb County. 20. Jurisdiction is proper in Dekalb County Superior Court as the majority of acts and/or omissions occurred in Dekalb County and the amount in controversy, exclusive of interest and costs, far exceeds the minimum jurisdictional limits of this Court. FACTS 21. On or about October 17, 2022, ANNIE JONES was initially admitted to BUCKHEAD CENTER FOR NURSING & HEALING (“BUCKHEAD CENTER”). At the time of her admission, she had a medical history that included: Parkinsons’ disease, type 2 diabetes mellitus without complications, muscle weakness, dysphagia, abnormalities of gait and mobility, need for assistance with personal care, gastro-esophageal reflux disease without esophagitis, anemia, mild protein-calorie malnutrition, anxiety disorder and hypertension. 22. On or about October 21, 2022, Ms. Jones was noted to be at risk of developing pressure ulcers but did not have any at the time of the assessment. The same assessment did not have any interventions for skin and ulcer/injury prevention including no turning and repositioning program. 23. On or about November 17, 2022, Ms. Jones was discharged home from BUCKHEAD CENTER. 24. On or about November 21, 2022, Ms. Jones was taken to Concentra Urgent care by her son. Concentra noted that when she was discharged from BUCKHEAD CENTER her son COMPLAINT Page 9 noted bedsores and a 20lb weight loss. He brought her to the local ER when she was discharged and was sent home with Keflex. He brought her to Concentra for pain management. Concentra noted that Ms. Jones had a stage 1 pressure injury to her right buttock. 25. On or about February 22, 2023, Ms. Jones was admitted to GLENWOOD HEALTH CENTER BY HARBORVIEW (“GLENWOOD HEALTH CENTER”). At the time of her admission, she had a medical history that included: hypertension, type 2 diabetes mellitus without complications, unspecified psychosis, Parkinson’s disease, disturbances of salivary secretion and urinary tract infection. 26. On or about February 23, 2022, a skin/wound progress note stated that Ms. Jones had no open areas but did indicate that an old scar area to the sacrum was observed and that it appeared to be “very fragile.” 27. By on or about March 21, 2023, Ms. Jones was noted to have an open area to her left buttock. The site measured 2.5 x 2.5 x 0.2 cm. 28. On or about April 5, 2023, Ms. Jones was noted to have an excoriated area that was open to the sacrum and left buttock. Combined, the sites measured 3.5 cm x 5 cm. At this time, she was also noted to have a poor appetite, incontinence and a very thin frame. 29. On or about June 30, 2023, a Braden Scale assessment found Ms. Jones to be an “8” on the scale-putting her at “very high risk” of developing pressure ulcers. 30. On or about July 2, 2023, Ms. Jones’s skin assessment showed healed wounds to the buttock and sacrum. Not long after, on or about July 17, 2023, Ms. Jones had a wound to her sacrum and buttocks measuring 7 cm x 10.5 cm due to moisture associated skin damage. COMPLAINT Page 10 31. On or about July 22, 2023, a skin assessment revealed an unstageable wound to the left buttock and sacral area measuring 7.5 cm x 5 cm x 0.1 cm with “scattered necrosis.” 32. On or about September 7, 2023, Ms. Jones was noted to have a stage III pressure ulcer to her sacrum measuring 5 cm x 7.0.1 cm. 33. On or about September 14, 2023, Ms. Jones was discharged from GLENWOOD HEALTH CENTER and moved to Fort Valley Nursing Home. 34. On or about September 19, 2023, Ms. Jones passed away. On the death certificate, her causes of death were listed as follows: pneumonia, malnutrition, diabetes myelitis and hypertension. 35. As skilled nursing facilities, the standard of care for BUCKHEAD CENTER and GLENWOOD HEALTH CENTER required that they provide care and treatment at a level that a reasonable, prudent similar facility and staff would provide under the same or similar circumstances. BUCKHEAD CENTER and GLENWOOD HEALTH CENTER, and their managers and operators, and nursing staff breached the standard of care in several ways. 36. Ms. Jones was at severe risk for pressure wound development. The standard of care was breached in that she did not receive every 2-hour turning and repositioning. Ms. Jones was incontinent of bladder and bowel. Nursing staff were required to place her on a 2-hour toileting schedule to ensure that her peri area was kept dry and to protect her skin from fragility and breakdown. They failed to do so, resulting in skin breakdown. 37. Management and owners of BUCKHEAD CENTER and GLENWOOD HEALTH CENTER were required to ensure that their nursing staff were provided with adequate training to provide care to residents. They were required to provide training and have in place policies and procedures for nursing staff to follow. They failed to do so. COMPLAINT Page 11 38. Management and operators of facilities such as BUCKHEAD CENTER and GLENWOOD HEALTH CENTER are required to ensure that care interventions are in place, that the care interventions are being followed and that the facility has policies and procedures, as well as sufficient staff to provide necessary care. To a reasonable degree of medical probability, this was not done by management and operations staff, thus leading to the injuries complained of in the care of Ms. Jones. 39. Defendants were well aware of ANNIE JONES'S medical condition and the care that she required when they represented that they could adequately care for his needs. Defendants made affirmative representations to the family that the appropriate level of care would be provided when the Defendants knew, because of budgetary restrictions on staffing and supplies, that residents, including ANNIE JONES, would not get the necessary care. 40. Defendants held themselves out as being: a. Skilled in the performance of nursing, rehabilitative, and other medical support services; b. Properly staffed, supervised, and equipped to meet the total needs of its nursing home residents; c. Providing around the clock skilled nursing care; d. Able to specifically meet the total nursing home, medical, and physical therapy needs of ANNIE JONES and other residents like her; and e. Licensed and complying on a continual basis with all rules, regulations, and standards established for nursing homes, nursing home licensees, and nursing home administrators as alleged herein. COMPLAINT Page 12 41. Defendants failed to discharge their obligations of care to ANNIE JONES. As a consequence thereof, ANNIE JONES suffered catastrophic injuries, disfigurement, extreme pain, suffering mental anguish, fright and death. The scope and severity of the recurrent wrongs inflicted upon ANNIE JONES while under the care of the facility accelerated the deterioration of her health and physical condition beyond that caused by the normal aging process and resulted in physical and emotional trauma which includes, but is not limited to: a. Pressure wounds; b. Urinary tract infections; c. Dehydration and malnutrition; d. Overmedication and/or incorrect medication monitoring; e. Poor hygiene and failure to provide for basic needs including but not limited to toileting, hygiene and mobility. and f. Death. 42. All of the above identified injuries, as well as the conduct specified herein, caused ANNIE JONES to lose her personal dignity and extreme and unnecessary pain, degradation, anguish, otherwise unnecessary hospitalizations, disfigurement, and emotional trauma. 43. The wrongs complained of herein were of a continuing nature and occurred throughout ANNIE JONES'S residency at Defendants' facility. 44. Defendants were aware of the systemic staffing problems at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER throughout the residency of ANNIE JONES via Summary Labor Reports, which were available at all levels of Defendants' corporate structure, these staffing failures directly impacted the care to the residents, including ANNIE JONES. COMPLAINT Page 13 45. Defendants, and each of them, were aware of the systemic problems within BUCKHEAD CENTER and GLENWOOD HEALTH CENTER relating to resident care, specifically including numerous falls resulting in significant injury and damage including those alleged herein by Ms. Jones. These care-based indicators were specifically selected after extensive research as indicators of the quality of care being provided to the residents, including ANNIE JONES. These quality indicators were monitored and available to the Defendants via monthly if not weekly reports. 46. Defendants' upper-level management conducted regular meetings for its different areas of operations including Georgia. These meetings kept all Defendants informed of the systemic problems at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER and the other facilities in Georgia. 47. Plaintiff alleges that on all of the occasions complained of herein, ANNIE JONES was under the care, supervision, and treatment of the agents and/or employees of Defendants and that the injuries complained of herein were proximately caused by the acts and omissions of Defendants named herein. 48. Defendants had vicarious liability for the acts and omissions of all persons or entities under Defendants' control, either directly or indirectly, including its employees, agents, consultants, and independent contractors, whether in-house or outside entities, individuals, agencies, or pools causing or contributing to the injuries of ANNIE JONES. 49. The Defendants are directly liable for the acts and/or omissions contained herein due to the direct control, ownership, and/or management of the operations of BUCKHEAD CENTER and GLENWOOD HEALTH CENTER. This exertion of control, ownership, and/or management by the Defendants created a dangerous environment for all residents, including ANNIE JONES. COMPLAINT Page 14 50. The Defendants were aware of the dangerous environment that was created by their methods of management and/or control at all their facilities, including BUCKHEAD CENTER and GLENWOOD HEALTH CENTER and the harm caused to the residents, including ANNIE JONES. 51. This methodology of management and/or control was set out in the Corporate Plan created and/or implemented by executives of the Nursing Home Defendants. 52. Defendants have joint and several liability for the actions complained of herein because they consciously and deliberately pursued a common plan or design to commit the tortious acts described in this Complaint and these Defendants actively took part in such actions. COUNT ONE CORPORATE NEGLIGENCE AGAINST NURSING HOME DEFENDANTS, THOMAS MARTENS, JOHN DOES (1-5) AND ABC CORPORATIONS (1-5) 53. Plaintiff re-alleges and incorporates all of the allegations in the Complaint as if set forth herein. 54. Nursing Home Defendants owed a duty to residents, including ANNIE JONES, to act in a manner consistent with the proper operation of the nursing homes they controlled, which a reasonably careful person/corporation would provide under similar circumstances. 55. Nursing Home Defendants' employees owed a duty to residents, including ANNIE JONES, to exercise reasonable care in providing oversight and management of the nursing homes they owned, operated, managed, and/or controlled. 56. Nursing Home Defendants breached this duty by failing to properly manage, operate, and/or control these nursing homes, including BUCKHEAD CENTER and GLENWOOD HEALTH CENTER, in a manner that a reasonably careful person/corporation would have provided under similar circumstances and by failing to properly allocate resources, provide appropriate policies and procedures, take appropriate corrective action when operational COMPLAINT Page 15 problems are brought to their attention, intentionally concealing the severity and existence of these failures from affected residents, and intentionally concealing the severity and existence of these failures from the State and Federal Government. 57. The negligence of the Nursing Home Defendants, their employees, agents, and consultants, includes, but is not limited to, one or more of the following acts and omissions: a. Staffing: i. Nursing home residents, including ANNIE JONES, often are unable to care for themselves; thus, they rely on nursing home staff to provide many, if not all, of their activities of daily living (ADL's). Nursing facilities have a common law duty, as well as a statutory duty, to have sufficient nursing staff to provide for the needs of their residents. ii. The Nursing Home Defendants are responsible and required to provide sufficient resources to hire and maintain sufficient staff to ensure that these residents' needs are met. iii. Additionally, when the Nursing Home Defendants fail to provide sufficient resources to hire and maintain sufficient staff, the staff who are present are unable to meet the total needs of the residents through no fault of their own. iv. When the Nursing Home Defendants fail to provide sufficient resources to hire and maintain sufficient staff, those who are present must take shortcuts with respect to all aspects of their job and are unable to do their job. v. Rather than hiring and maintaining sufficient staff, Separate Defendants hired too few registered nurses, too few LPNs, and too few certified nursing assistants. More importantly, too many of these staff members skipped work or terminated their employment because they did not have enough co- COMPLAINT Page 16 workers to properly care for the residents who depended upon them, or because of deplorable working conditions, or because the pay set by these Corporate Defendants was too low, or such other reasons as will be proven at trial of this matter. b. Nursing Home Defendants failed to implement adequate guidelines, policies, and procedures for: i. Investigating the relevant facts, underlying deficiencies, or licensure violations or penalties found to exist at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER by the Georgia Department of Community Health or any state or federal survey agency; ii. Determining the cause of any such deficiencies, violations or penalties; iii. Correcting deficiencies or licensure violations or penalties found to exist at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER; and iv. Notifying residents affected by and those potentially affected by deficiencies cited by any state or federal survey agency. c. Nursing Home Defendants failed to adopt adequate guidelines, policies, and procedures for determining whether BUCKHEAD CENTER and GLENWOOD HEALTH CENTER had sufficient numbers of nursing personnel to: i. Provide 24-hour compliance with all contracts, all state statutes, or rules, and/or all applicable federal statutes or regulations; and ii. To correct and address any and all failures to comply with all contracts, all state statutes or rules, and/or all applicable federal statutes or regulations. d. Nursing Home Defendants failed to adopt adequate guidelines, policies, and procedures at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER for COMPLAINT Page 17 documenting, maintaining files, investigating and responding to any complaint regarding compliance with all contracts, all state statutes or rules, and/or all applicable federal statutes or regulations by employees at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER regardless of whether such complaint derived from a state survey agency, a resident of the facility, an employee of the facility, or any interested person. This failure resulted in injury, abuse, and neglect to residents of the facility, including ANNIE JONES. e. Budgeting or Allocation of Resources: i. Nursing Home Defendants were responsible for providing accurate information regarding the monetary needs of the facility so that a workable budget could be set. ii. Nursing Home Defendants were required to administer BUCKHEAD CENTER and GLENWOOD HEALTH CENTER in a manner that enabled it to use resources effectively and efficiently to comply with all contracts, all state statutes or rules, and/or all applicable federal statutes or regulations. iii. Nursing Home Defendants were responsible for allocating funds within the budget in a manner that ensured compliance with all contracts, all state statutes or rules, and/or all applicable federal statutes or regulations. iv. Nursing Home Defendants failed to properly allocate the budgetary needs of the facility and to properly allocate the funds budgeted to the facility for compliance with all contracts, all state statutes or rules, and/or all applicable federal statutes or regulations, resulting in the following: COMPLAINT Page 18 1. Staffing levels that were insufficient to comply with all contracts, all state statutes or rules, and/or all applicable federal statutes or regulations for each resident, including ANNIE JONES. 2. Supplies and food were insufficient to comply with all contracts, all state statutes or rules, and/or all applicable federal statutes or regulations for each resident, including ANNIE JONES. 3. Upon information and belief, Plaintiff alleges that rather than properly allocating the budgeted funds, Nursing Home Defendants inappropriately allocated or allowed funds to be paid to management companies that did not assist or even participate in managing the care provided to the residents. Rather, Nursing Home Defendants only enhanced the profits of the home, allocated funds to employees whose only duties were non-patient oriented, and to items and services that were unnecessary to achieve the proper goal of compliance with all contracts, all state statutes or rules, and/or all applicable federal statutes or regulations. v. The failure to adequately budget and allocate resources to the facility directly caused damages to ANNIE JONES. f. Corporate Compliance and Reporting. i. Nursing Home Defendants were responsible for ensuring that the facility complied with state and federal standards as to the residents of the home. To that end, they were required to file various reports with regulatory entities. COMPLAINT Page 19 ii. Nursing Home Defendants were charged with the responsibility of reporting instances of noncompliance with all contracts, all state statutes or rules, and/or all applicable federal statutes or regulations that occurred at the facility. Upon information and belief, Plaintiff alleges that their failure to properly and timely do so resulted in additional injuries to residents, including ANNIE JONES. iii. Upon information and belief, Plaintiff alleges that Nursing Home Defendants failed to properly recognize and report instances of non- compliance occurring at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER, and further failed to correct those instances. These failures to report resulted in the appearance of a facility that was properly managed and maintained. This false and misleading appearance induced the family of BUCKHEAD CENTER and GLENWOOD HEALTH CENTER to place her in the facility and misled them as to the facility's compliance with all contracts, all state statutes or rules, and/or all applicable federal statutes or regulations. Further, upon information and belief, Plaintiff alleges that because certain problems were not reported or were under- reported, the facility escaped inspections and investigations by regulatory agencies and even in-house reviews that might have corrected the deficiencies. These deficiencies that the facility experienced created a more dangerous environment in which additional injuries could occur to residents, including ANNIE JONES. iv. Corporate Defendants were responsible for ensuring that no claims for reimbursement were submitted to the federal or state governments for COMPLAINT Page 20 services that were not provided, or services provided that did not comply with all contracts, all state statutes or rules, and/or all applicable federal statutes or regulations. Upon information and belief, Corporate Defendants submitted inaccurate claims as a result of the various staffing issues listed above, resulting in unjust enrichment to the facility. v. The failure to adequately comply with and report violations of state and federal standards directly caused harm to ANNIE JONES. 58. A reasonably careful Corporation, operating under similar circumstances, would foresee that the failure to provide the appropriate oversight, management, direction, and/or control would result in poorly operated nursing homes such as BUCKHEAD CENTER and GLENWOOD HEALTH CENTER and devastating injuries to residents including ANNIE JONES. 59. As a direct and proximate result of the negligence of Nursing Home Defendants as set out above, ANNIE JONES suffered injuries, including pressure sores, infections, and also suffered extreme pain, suffering, mental anguish, embarrassment, fright and death, all of which required hospitalization and medical treatment, and required ANNIE JONES to incur significant hospital and medical expenses. 60. WHEREFORE, based on such conduct of Nursing Home Defendants as set forth above, Plaintiff asserts a claim for judgment for all compensatory damages and punitive damages against Nursing Home Defendants including, but not limited to, medical expenses, physical pain, suffering, mental anguish, disability, loss of enjoyment of life, humiliation, disfigurement, fright and death in an amount to be determined by the jury, plus costs and all other relief to which Plaintiff is entitled by law. COMPLAINT Page 21 COUNT TWO NEGLIGENCE CLAIM AGAINST ADMINISTRATOR DEFENDANTS AND JOHN DOES (1 -5) 61. Plaintiff re-alleges and incorporates all of the allegations in the Complaint as if set forth herein. 62. Upon information and belief, Administrator Defendant and John Does (1-5), were the administrators of BUCKHEAD CENTER and GLENWOOD HEALTH CENTER during the residency of ANNIE JONES. To the extent the names of the licensed administrators who may have managed this facility during the residency of ANNIE JONES are determined, all of the following acts are properly attributed to them, and Plaintiff will seek leave to substitute these individuals as proper party Defendants. 63. As nursing home administrators, Administrator Defendants owed a common law duty to act as reasonably prudent nursing home administrators and to prevent all reasonably foreseeable injuries to the residents of BUCKHEAD CENTER and GLENWOOD HEALTH CENTER. 64. As nursing home administrators, Administrator Defendants owed a common law duty to remain informed as to events occurring at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER through contact with the various departments that they managed, including, but not limited to, nursing, dietary, therapy, housekeeping, social services, and maintenance. Administrator Defendants were required under law to be aware of matters occurring at the nursing home and to take affirmative steps to correct problems, particularly when those problems could reasonably cause or contribute to an injury, abuse, or neglect to residents of the home. COMPLAINT Page 22 65. When Administrator Defendants accepted the position of administrator of BUCKHEAD CENTER and GLENWOOD HEALTH CENTER, they assumed the duties as set forth in the preceding paragraphs. 66. It is reasonably foreseeable that injuries, abuse, and neglect to residents of BUCKHEAD CENTER and GLENWOOD HEALTH CENTER, including ANNIE JONES, would occur as a direct result of Administrator Defendants' failures to carry out their duties as administrators of the facility. 67. As nursing home administrators, Administrator Defendants were centrally involved and actively participated in tortious conduct that directly caused or contributed to the injuries of ANNIE JONES. The following areas describe with specificity the wrongdoings of Administrator Defendants that resulted in harm to ANNIE JONES: a. Staffing: i. Nursing home residents, including ANNIE JONES, often are unable to care for themselves; thus, they rely on nursing home staff to provide many, if not all, of their activities of daily living. Nursing facilities have a common law duty, as well as a statutory duty, to have sufficient nursing staff to provide for the needs of their residents. ii. The administrator is responsible and required to hire and maintain sufficient staff to ensure that these residents' needs are met. Further, the administrator must establish and maintain proper working relationships with physicians, nurse practitioners, and employees of the facility. iii. When the administrator, as here, fails to hire and maintain sufficient staff and fails to maintain proper working relationships between the departments of the facility, the residents do not receive adequate and appropriate care. COMPLAINT Page 23 iv. Additionally, when the administrator fails to hire and maintain sufficient staff, the staff who are present are unable to meet the total needs of the residents through no fault of their own. v. When the administrator fails to hire and maintain sufficient staff, those who are present must take shortcuts with respect to the care provided and are unable to provide adequate and appropriate care to the residents of the facility. vi. Rather than hiring and maintaining sufficient staff, Administrator Defendants hired too few registered nurses, too few LPNs, and too few certified nurse assistants. More importantly, too many of these staff members skipped work or terminated their employment because they did not have enough co-workers to properly care for the residents who depended upon them, or because of deplorable working conditions, or because the pay set by the nursing home with the input of the administrator was too low, or such other reasons as will be proven at trial of this matter. vii. Administrator Defendants failed to develop and maintain proper working relationships between physicians, nurse practitioners and employees of the facility, and between the various departments they managed. ANNIE JONES was injured through their failure to manage these individuals and departments in a way that they could fluidly and seamlessly work together. viii. Due to staff shortages at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER, ANNIE JONES'S medical records were not kept and maintained in accordance with accepted professional standards and practices. This incomplete documentation resulted in further injuries to COMPLAINT Page 24 ANNIE JONES-the facility was unable to properly understand her condition, changes that occurred in her condition, and whether or not her care plan and dietary assessments were properly modified to address changes in her condition. ix. Administrator Defendants owed a non-delegable duty to ANNIE JONES and other residents of BUCKHEAD CENTER and GLENWOOD HEALTH CENTER, during their tenure as administrators, to ensure adequate and appropriate custodial care and supervision through their control over staffing issues. A reasonably prudent nursing home administrator would have known or should have known that injuries would occur to residents such as ANNIE JONES if staffing levels were not maintained within reasonable parameters. x. With respect to staffing, the failures of Separate Defendants include but are not limited to: 1. Ensuring that the staff provided ANNIE JONES adequate hygiene and sanitary care; 2. Ensuring that the staff provided ANNIE JONES clean bed linens to prevent urine and fecal contact for extended periods of time; 3. Providing sufficient numbers of qualified personnel, including nurses, licensed practical nurses, certified nurse assistants, and medication aides (nursing personnel) to meet the total needs of ANNIE JONES throughout her residency; and 4. Ensuring that ANNIE JONES: a. Received timely and accurate care assessments; COMPLAINT Page 25 b. Received prescribed treatment, medication and diet; c. Was protected from accidental or intentional injuries by the correct use of ordered and reasonable safety measures and proper supervision of staff and other residents; d. Keeping ANNIE JONES clean and comfortable and to prevent the formation of bedsores, ulcers and lesions on his body; e. Providing a safe environment free from preventable abuse and neglect; f. Ensuring that ANNIE JONES received care, treatment, and medication in accordance with physician's orders; and g. Ensuring that ANNIE JONES was provided with the dignity and respect that all nursing home residents are entitled to receive. xi. Adequately screen, evaluate and check references, test for competence, and use ordinary care in selecting nursing personnel to work at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER; xii. Terminating employees at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER that were known (or should have been known) to be careless, incompetent, and unwilling to comply with the policy and procedures of the facility and the rules and regulations promulgated and adopted by the Georgia Division of Health; COMPLAINT Page 26 xiii. Assigning nursing personnel at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER consistent with their education and experience and based on: 1. ANNIE JONES'S medical history and condition, nursing, and rehabilitative needs; 2. The characteristics of the resident population residing in the area of the facility where ANNIE JONES was a resident; and 3. Nursing skills needed to provide care for such resident population. b. Administrator Defendants failed to implement adequate guidelines, policies, and procedures for: i. Investigating the relevant facts, underlying deficiencies, or licensure violations or penalties found to exist at BUCKHEAD CENTER and GLENWOOD HEALTH CENTER by any state or federal survey agency; ii. Determining the cause of any such deficiencies, violations, or penalties; and iii. Correcting deficiencies or licensure violations or penalties found to