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DEPARTMENT OF HEALTH AND HUMAN SERVICES

DIVISION OF HEALTH SERVICE REGULATION


ROY COOPER MANDY COHEN, MD, MPH
GOVERNOR SECRETARY

MARK PAYNE
DIRECTOR
Certified Mail and Regular Mail
#7016 2140 0000 4121 0148

March 23, 2017

T. Andrew Smith, Executive Officer


Southern Assisted Living, LLC, Licensee
Brookdale Elizabeth City
401 Hastings Lane
Elizabeth City, North Carolina 27909

Email: jeisenhaure@brookdale.com

RE: Suspension of Admissions


Facility Name: Brookdale Elizabeth City
Licensure Number: HAL-070-005
County: Pasquotank

Dear Mr. Smith:

Based on the information and recommendations submitted by our staff and the Pasquotank County Department of Social
Services, we find that your facility has failed to comply with Articles 1 and 3 of Chapter 131D of the North Carolina
General Statues and the rules adopted pursuant to these articles.

The documented violations indicate that conditions in the home are found to be detrimental to the health and safety of the
residents. Therefore, you are hereby ordered to suspend all admissions to the home effective immediately. The
Suspension of Admissions is to continue until conditions or circumstances merit removing the suspension.

The agencys decision is based upon the findings in the Statement of Deficiencies dated February 28, 2017(Annual/
Follow-up Survey and Compliant Investigation), which has already been mailed or provided to you. If you do not
have a copy of the document(s), please contact us at (919) 855-3765.

ADULT CARE LICENSURE SECTION


www.ncdhhs.gov
TEL 919-855-3765 FAX 919-733-9379
LOCATION: BROWN BUILDING 801 BIGGS DRIVE RALEIGH, NC 27603
MAILING ADDRESS: 2708 MAIL SERVICE CENTER RALEIGH, NC 27699-2708
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
Page 2 of 3
Brookdale Elizabeth City
HAL-070-005
March 23, 2017

Suspension of Admissions

Appeal Notice

You have the right to contest the above action within 20 days after the mailing of this notice, in accordance with G.S.
150B, Article 3 and G.S. 131D-2.7. Should you decide to appeal the above adverse action, please be advised that G.S.
150B-22 encourages the settlement of disputes through informal procedures to assist in resolving any dispute you may
have with our findings or proposed action.

For complete instructions on filing of petitions, please contact the Office of Administrative Hearings at (919) 431-3000.
The mailing address for the Office of Administrative Hearings is as follows:

Office of Administrative Hearings


6714 Mail Service Center
Raleigh, NC 27699-6700

150B-23.2. Fee for filing a contested case hearing.


(a) Filing Fee. In every contested case commenced in the Office of Administrative Hearings by a person aggrieved, the
petitioner shall pay a filing fee, and the administrative law judge shall have the authority to assess that filing fee against the losing
party, in the amount of one hundred twenty-five dollars ($125.00), unless the Office of Administrative Hearings establishes a lesser
filing fee by rule.
(b) Time of Collection. All fees that are required to be assessed, collected, and remitted under subsection (a) of this section
shall be collected by the Office of Administrative Hearings at the time of commencement of the contested case (except in suits in
forma pauperis).
(c) Forms of Payment. The Office of Administrative Hearings may by rule provide for the acceptable forms for payment
and transmission of the filing fee.
(d) Wavier or Refund. The Office of Administrative Hearings shall by rule provide for the fee to be waived in a contested
case in which the petition is filed in forma pauperis and supported by such proofs as are required in G.S. 1-110 and in a contested case
involving a mandated federal cause of action. The Office of Administrative Hearings shall by rule provide for the fee to be refunded in
a contested case in which the losing party is the State. (2009-451, s. 21A.1 (b).)

N.C. General Statute 150B-23 provides that you must also serve a copy of the petition on all other parties, which
includes the Department of Health and Human Services. The Departments representative for such action is Lisa G.
Corbett, General Counsel. This person may receive service of process by mail at the following address:

Lisa G. Corbett
Department of Health and Human Services
Office of Legal Affairs
Adams Building
2001 Mail Services Center
Raleigh, NC 27699-2001

If you do not file a petition within the 20 day period, you lose your right to appeal. In addition to your right to file a
petition of a contested case hearing, N.C. General Statute 150B-22 encourages the settlement of disputes through
informal procedures. In keeping with this law, this office remains readily available for discussion or other informal
procedures to assist in resolving any dispute you may have with our findings and action.

ADULT CARE LICENSURE SECTION


www.ncdhhs.gov
TEL 919-855-3765 FAX 919-733-9379
LOCATION: BROWN BUILDING 801 BIGGS DRIVE RALEIGH, NC 27603
MAILING ADDRESS: 2708 MAIL SERVICE CENTER RALEIGH, NC 27699-2708
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER
Page 3 of 3
Brookdale Elizabeth City
HAL-070-005
March 23, 2017

Should you have any questions regarding any aspect of this letter, please do not hesitate to contact me at the Department
of Health and Human Services, Division of Health Service Regulation, Adult Care Licensure Section, 2708 Mail Service
Center, Raleigh, North Carolina 27699-2708 or call me at (919) 855-3765.

Sincerely,

Megan Lamphere, MSW


Chief, Adult Care Licensure Section

Enclosures: Intent for Provisional License

cc: Jeanne Eisenhaure, Administrator, w/enclosures (included in certified mailing # 70162140000041210148)


Victor Orija, Division of Aging and Adult Services
Special Assistance, Division of Aging and Adult Services
Construction Section, Division of Health Service Regulation
Carolyn Perry, Supervisor/Designee, Pasquotank County DSS Name
Libby Kinsey, Assistant Chief, Adult Care Licensure Section
Marie Rodgers, Branch Manager, Eastern Region, Adult Care Licensure Section
Paulette Brock-Fogg, Adult Care Licensure Section
Star Rating Program, Adult Care Licensure Section
Raleigh Office Facility File

ADULT CARE LICENSURE SECTION


www.ncdhhs.gov
TEL 919-855-3765 FAX 919-733-9379
LOCATION: BROWN BUILDING 801 BIGGS DRIVE RALEIGH, NC 27603
MAILING ADDRESS: 2708 MAIL SERVICE CENTER RALEIGH, NC 27699-2708
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER