Arkansas Nursing Home Resident Complaint — OLTC and Long-Term Care Ombudsman

COMPLAINT — VIOLATION OF NURSING HOME RESIDENT RIGHTS — ARKANSAS

TABLE OF CONTENTS

1. Filing Cover Sheet
2. Resident Information
3. Complainant Information
4. Facility Information
5. Statutory and Regulatory Basis
6. Specific Violations Alleged
7. Factual Narrative
8. Evidence and Witnesses
9. Harm and Damages
10. Relief Requested
11. Concurrent Filings
12. Immunity and Anti-Retaliation Notice
13. Verification and Signature
14. Sources and References

1. FILING COVER SHEET

2. RESIDENT INFORMATION

2.1. Resident name: [________________________________]

2.2. Date of birth: [__/__/____]

2.3. Gender: ☐ M ☐ F ☐ Other

2.4. Date of admission to facility: [__/__/____]

2.5. Resident's room number / unit: [________________________________]

2.6. Payor source: ☐ Medicare ☐ Medicaid (NF) ☐ Private pay ☐ LTC insurance ☐ Other [____________]

2.7. Resident has decisional capacity: ☐ Yes ☐ No ☐ Diminished

2.8. Legal representative (guardian, POA, health-care surrogate): [________________________________]

2.9. Diagnoses relevant to complaint: [________________________________]

3. COMPLAINANT INFORMATION

3.1. Name: [________________________________]

3.2. Relationship to resident: ☐ Self ☐ Spouse ☐ Adult child ☐ Other relative ☐ Friend ☐ Guardian / POA ☐ Mandated reporter ☐ Ombudsman ☐ Facility employee (whistleblower) ☐ Other [____________]

3.3. Address: [________________________________]

3.4. Telephone: [________________________________]

3.5. Email: [________________________________]

3.6. Confidentiality requested: ☐ Yes — withhold complainant identity to extent permitted by law (Ark. Code Ann. § 20-10-1206; 42 U.S.C. § 3058g(d) Ombudsman confidentiality) ☐ No

3.7. Authority to file on behalf of resident: ☐ Resident ☐ Court-appointed guardian (Letters attached) ☐ Durable Power of Attorney (attached) ☐ Health-care surrogate ☐ Concerned person (anonymous reports permitted)

4. FACILITY INFORMATION

5. STATUTORY AND REGULATORY BASIS

This complaint is filed under, and the facility's conduct violates, the following:

5.1. Federal Nursing Home Reform Act (OBRA-87) / 42 U.S.C. § 1396r and 42 C.F.R. Part 483 — establishes the federal "Residents' Bill of Rights," including the right to a dignified existence, self-determination, freedom from abuse and neglect, freedom from chemical and physical restraints used for discipline or convenience, and the right to participate in care planning.

5.2. 42 C.F.R. § 483.10 — resident rights, including: exercise of rights without interference; notification of rights; privacy and confidentiality; grievance procedures; access to records; choice of attending physician.

5.3. 42 C.F.R. § 483.12 — freedom from abuse, neglect, and exploitation; mandatory facility reporting and investigation duties.

5.4. 42 C.F.R. § 483.15 — admission, transfer, and discharge rights, including an ordinary rule of at least 30 days' written notice, subject to the listed shorter-notice circumstances, and notice of appeal rights.

5.5. 42 C.F.R. § 483.21 — comprehensive person-centered care planning and assessment requirements.

5.6. 42 C.F.R. § 483.24, § 483.25 — quality of life and quality of care requirements.

5.7. Older Americans Act, 42 U.S.C. § 3058g — Long-Term Care Ombudsman Program; access to residents and records.

5.8. Ark. Code Ann. § 20-10-1204 — Arkansas residents' rights, including but not limited to: civil and religious liberties; private and uncensored communications; privacy in treatment and personal needs; freedom from mental and physical abuse; freedom from chemical and physical restraints except as authorized by physician for limited time; participation in care planning; refusal of treatment; access to ombudsman; right to manage personal financial affairs; written statement of rights upon admission.

5.9. Ark. Code Ann. § 20-10-1206 — complaint procedure; immunity from civil liability for good-faith reporters and witnesses.

5.10. Ark. Code Ann. § 20-10-1207 — DHS investigation and enforcement authority.

5.11. Ark. Code Ann. § 20-10-1209 — civil action by resident or representative for violation of residents' rights; recovery of actual damages, punitive damages, attorneys' fees, costs, and injunctive relief; one-year statute of limitations for actions under this section (verify against current statute).

5.12. Ark. Code Ann. § 12-12-1701 et seq. — Adult and Long-Term Care Facility Resident Maltreatment Act; mandatory reporting.

6. SPECIFIC VIOLATIONS ALLEGED

Check every right or requirement the facility has violated. Each box requires a corresponding factual allegation in Section 7.

Federal F-Tag / 42 C.F.R. Part 483 violations:

• ☐ F550 — Resident rights / dignity (§ 483.10(a), (b))
• ☐ F580 — Notification of changes (§ 483.10(g))
• ☐ F600 — Free from abuse and neglect (§ 483.12(a))
• ☐ F602 — Free from misappropriation / exploitation
• ☐ F604 — Right to be free from physical restraints (§ 483.10(e))
• ☐ F605 — Right to be free from chemical restraints
• ☐ F607 — Develop / implement abuse-prevention policies (§ 483.12(b))
• ☐ F609 — Reporting of alleged violations (§ 483.12(c))
• ☐ F622 — Transfer and discharge requirements (§ 483.15)
• ☐ F623 — Notice requirements before transfer / discharge
• ☐ F656 — Comprehensive care plan (§ 483.21(b))
• ☐ F684 — Quality of care (§ 483.25)
• ☐ F686 — Pressure injuries / ulcers (§ 483.25(b))
• ☐ F689 — Free from accident hazards / supervision / assistance (§ 483.25(d))
• ☐ F690 — Bowel / bladder incontinence; catheter; UTI
• ☐ F692 — Nutrition / hydration (§ 483.25(g))
• ☐ F695 — Respiratory / tracheostomy / suctioning care
• ☐ F698 — Dialysis
• ☐ F740 — Behavioral health services (§ 483.40)
• ☐ F741 — Sufficient and competent staff for behavioral-health needs
• ☐ F758 — Free from unnecessary psychotropic medications
• ☐ F761 — Medication labeling / storage
• ☐ F812 — Food safety / sanitation (§ 483.60)
• ☐ F880 — Infection prevention and control (§ 483.80)

Arkansas § 20-10-1204 rights violations:

• ☐ Right to civil and religious liberties
• ☐ Right to private and uncensored communication (mail, telephone, visitors)
• ☐ Right to participate in social, religious, and community group activities
• ☐ Right to manage personal financial affairs / receive accountings
• ☐ Right to be fully informed of medical condition
• ☐ Right to refuse treatment / participate in experimental research
• ☐ Right to receive adequate and appropriate health care
• ☐ Right to privacy in treatment
• ☐ Right to be treated courteously and with dignity
• ☐ Right to be free from mental and physical abuse
• ☐ Freedom from physical and chemical restraints except as authorized by physician for limited time
• ☐ Right to be transferred or discharged only for medical reasons, welfare, non-payment, or facility closure, with adequate notice and appeal rights
• ☐ Right of access to LTC Ombudsman and adult-abuse registry; right to file complaints free from retaliation
• ☐ Right to written notice of rights upon admission and posted in conspicuous location

7. FACTUAL NARRATIVE

Provide a chronological, fact-specific account. Use first-person if complainant is the resident; otherwise third-person. Identify dates, times, locations within facility, and persons present. Avoid conclusions; describe what was observed and said.

7.1. Background. [____________________________________________________________]

7.2. First incident — Date [__/__/____], Time [__:__]: [____________________________________________________________]

7.3. Subsequent incidents (chronological): [____________________________________________________________]

7.4. Facility's response (or non-response) to grievances raised internally: [____________________________________________________________]

7.5. Pattern, frequency, and continuing nature of conduct: [____________________________________________________________]

7.6. Statements made by facility staff (verbatim where possible): [____________________________________________________________]

8. EVIDENCE AND WITNESSES

8.1. Documents requested or in possession:

• ☐ Medical records (resident is entitled to copy under § 483.10(g)(2))
• ☐ Medication Administration Records (MARs)
• ☐ Treatment Administration Records (TARs)
• ☐ ADL flow sheets / nursing notes
• ☐ MDS / RAI assessments
• ☐ Care plans (current and prior)
• ☐ Incident / accident reports
• ☐ Grievance log entries
• ☐ Photographs of injuries / conditions
• ☐ Trust-fund accountings (resident's personal funds)
• ☐ Discharge / transfer notice
• ☐ Other: [________________________________]

8.2. Witnesses:

8.3. Has the resident, family, or complainant communicated with the facility internally? ☐ Yes — describe responses received: [________________________________] ☐ No

9. HARM AND DAMAGES

9.1. Physical injury or condition: [________________________________]

9.2. Hospitalization or ER visits attributable to the conduct: [________________________________]

9.3. Pain, suffering, loss of dignity, mental anguish: [________________________________]

9.4. Financial loss / theft / exploitation amount: $[________]

9.5. Need for additional medical care, equipment, or therapy: [________________________________]

9.6. Risk of further harm if not addressed: [________________________________]

10. RELIEF REQUESTED

Complainant requests that the receiving authority:

• ☐ Investigate. Conduct a prompt unannounced investigation under 42 C.F.R. § 488.332 and Ark. Code Ann. § 20-10-1207.
• ☐ Substantiate violations. Cite the facility for each F-tag and Arkansas residents'-right violation found.
• ☐ Immediate jeopardy. Determine whether immediate-jeopardy conditions exist and impose appropriate remedies under 42 C.F.R. § 488.408.
• ☐ Civil monetary penalties. Recommend CMPs and other federal enforcement remedies.
• ☐ Plan of correction. Require an acceptable plan of correction with verification.
• ☐ Refer to Adult Maltreatment Hotline. Cross-report to DHS APS and the LTC Maltreatment Central Registry under Ark. Code Ann. § 12-12-1716.
• ☐ Refer to law enforcement. Refer for criminal investigation where conduct constitutes a crime.
• ☐ Refer to AG Medicaid Fraud Control Unit (MFCU). For abuse, neglect, or financial exploitation in Medicaid-funded settings.
• ☐ Protect the resident. Coordinate with the LTC Ombudsman and, if necessary, facilitate transfer to a safe environment.
• ☐ Protect the complainant from retaliation and prohibit any adverse action against the resident or family.
• ☐ Provide written disposition to complainant under § 20-10-1207.

10.1. Civil action. Complainant reserves the right to bring a civil action under Ark. Code Ann. § 20-10-1209 for actual damages, punitive damages, attorneys' fees, costs, and injunctive relief, and under any other available state or federal cause of action including negligence and breach of fiduciary duty.

11. CONCURRENT FILINGS

This complaint, or a substantively identical complaint, has also been filed with:

• ☐ Office of Long-Term Care, DHS — 1-800-582-4887 / [email protected] on [__/__/____]
• ☐ Arkansas Long-Term Care Ombudsman — on [__/__/____]
• ☐ Adult Maltreatment Hotline — 1-800-482-8049 on [__/__/____]
• ☐ CMS Region VI (Dallas) — for federally certified facilities
• ☐ Arkansas Attorney General — Medicaid Fraud Control Unit / Public Protection
• ☐ Local law enforcement: [________________________________]
• ☐ Prosecuting Attorney, [____________] Judicial District
• ☐ Facility licensing board for individual professionals: [________________________________]
• ☐ Long-Term-Care Insurance carrier (for documentation): [________________________________]

12. IMMUNITY AND ANTI-RETALIATION NOTICE

12.1. Immunity. Under Ark. Code Ann. § 20-10-1206, any person who in good faith submits a complaint or testifies in any administrative or judicial proceeding arising from a complaint shall have immunity from civil liability except where the person acted in bad faith or with malicious purpose, or where the court finds a complete absence of a justiciable issue of law or fact.

12.2. Ombudsman confidentiality. Communications with the Arkansas Long-Term Care Ombudsman are confidential under 42 U.S.C. § 3058g(d) and applicable AoA regulations; identifying information may not be disclosed without the consent of the resident or representative.

12.3. Anti-retaliation. Federal regulation 42 C.F.R. § 483.10(j)(1) protects a resident's right to voice grievances without discrimination or reprisal. Apply Arkansas law separately to any representative, complainant, or conduct outside that federal resident-grievance right. Suspected retaliation should be reported immediately and evaluated under the provision protecting the person and activity involved.

12.4. Mandated reporting cross-reference. If this complaint alleges abuse, neglect, or exploitation by a caregiver, the facility, complainant, or any mandated reporter must comply with the immediate-report duty of Ark. Code Ann. § 12-12-1708.

13. VERIFICATION AND SIGNATURE

I declare under penalty of perjury under the laws of the State of Arkansas that the foregoing complaint is true and correct to the best of my knowledge, information, and belief, and is submitted in good faith.

[________________________________]

[COMPLAINANT NAME]

Relationship: [____________________]

Date: [__/__/____]

Telephone: [____________________]

Email: [____________________]

STATE OF ARKANSAS

COUNTY OF [____________]

Sworn to and subscribed before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public

(My Commission Expires: [_______________])

14. SOURCES AND REFERENCES

• 42 U.S.C. § 1396r (Federal Nursing Home Reform Act / OBRA-87) — https://www.law.cornell.edu/uscode/text/42/1396r
• 42 U.S.C. § 1395i-3 (Medicare SNF requirements) — https://www.law.cornell.edu/uscode/text/42/1395i-3
• 42 C.F.R. Part 483 (long-term-care facility requirements) — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• 42 C.F.R. § 483.10 (resident rights) — https://www.ecfr.gov/current/title-42/section-483.10
• 42 C.F.R. § 483.12 (freedom from abuse) — https://www.ecfr.gov/current/title-42/section-483.12
• Older Americans Act / LTC Ombudsman, 42 U.S.C. § 3058g — https://www.law.cornell.edu/uscode/text/42/3058g
• Ark. Code Ann. Title 20, Ch. 10, Subch. 12 (Protection of Long-Term Care Facility Residents) — https://law.justia.com/codes/arkansas/title-20/subtitle-2/chapter-10/subchapter-12/
• Ark. Code Ann. § 20-10-1204 (residents' rights) — https://law.justia.com/codes/arkansas/title-20/subtitle-2/chapter-10/subchapter-12/section-20-10-1204/
• Arkansas DHS Office of Long-Term Care — https://humanservices.arkansas.gov/divisions-shared-services/provider-services-quality-assurance/office-of-long-term-care/
• OLTC Complaint Hotline: 1-800-582-4887 | [email protected] | Fax: 501-682-8540
• Arkansas Long-Term Care Ombudsman — https://arombudsman.dhs.arkansas.gov/
• Arkansas DHS — Report a Concern — https://humanservices.arkansas.gov/report-a-concern/
• Adult Maltreatment Hotline: 1-800-482-8049
• CMS Nursing Home Survey & Enforcement (SOM Appendix PP) — https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS1201984
• AR Attorney General — Elder Abuse / Public Protection — https://arkansasag.gov/divisions/public-protection/seniors/elder-abuse/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. The Arkansas private right of action under Ark. Code Ann. § 20-10-1209 is subject to a short limitations period; consult a licensed Arkansas attorney promptly if litigation is contemplated. Verify all citations and current contact information before filing.