Arizona Nursing Home Resident Rights Complaint (ADHS / LTC Ombudsman)

Arizona Nursing Home Resident Rights Complaint

Where to File This Complaint

Part I — Complainant (Person Filing)

Part II — Resident

Part III — Facility

Part IV — Resident Rights Violated

Check ALL that apply. Resident rights are codified at 42 C.F.R. § 483.10 (NHRA) and Arizona regulations A.A.C. R9-10-410 et seq. Each item below references the controlling provision.

A. Quality of Life and Dignity

☐ Failure to treat resident with dignity and respect (42 C.F.R. § 483.10(a))
☐ Verbal, mental, or physical abuse by staff (42 C.F.R. § 483.12; A.R.S. § 46-454)
☐ Use of physical or chemical restraints not authorized to treat medical symptoms (42 C.F.R. § 483.10(e), § 483.12(a)(2))
☐ Failure to accommodate individual needs and preferences (42 C.F.R. § 483.10(e)(3))

B. Self-Determination

☐ Denial of right to make treatment decisions / right to refuse treatment (42 C.F.R. § 483.10(c))
☐ Failure to honor advance directive / DNR / health-care POA (A.R.S. § 36-3201 et seq.)
☐ Denial of right to choose attending physician (42 C.F.R. § 483.10(d))
☐ Denial of right to participate in care planning (42 C.F.R. § 483.10(c)(2))

C. Information and Communication

☐ Failure to provide written notice of rights upon admission (42 C.F.R. § 483.10(g))
☐ Failure to provide notice of rate changes / Medicare or Medicaid coverage changes (42 C.F.R. § 483.10(g)(17), (18))
☐ Denial of access to medical records within 24 hours / copies within 2 working days (42 C.F.R. § 483.10(g)(2))
☐ Failure to communicate in language resident understands (42 C.F.R. § 483.10(g)(3))

D. Privacy and Confidentiality

☐ Violation of privacy in treatment, written/telephonic communication, visits (42 C.F.R. § 483.10(h))
☐ Disclosure of medical or personal records without authorization (42 C.F.R. § 483.10(h)(3); HIPAA)

E. Visitation and Association

☐ Denial of immediate access by family, ombudsman, physician, APS, or representative of resident's choice (42 C.F.R. § 483.10(f)(4))
☐ Denial of reasonable visitation hours
☐ Denial of right to organize / participate in resident or family councils (42 C.F.R. § 483.10(f)(5))

F. Personal Property and Funds

☐ Theft, loss, or damage to personal property (A.A.C. R9-10-410)
☐ Mismanagement of resident's personal funds account (42 C.F.R. § 483.10(f)(10))
☐ Failure to provide quarterly accounting of personal funds
☐ Charge for items/services covered by Medicare or Medicaid (42 C.F.R. § 483.10(f)(11))

G. Transfer and Discharge

☐ Improper involuntary transfer or discharge — no valid statutory basis (42 C.F.R. § 483.15(c))
☐ Failure to give 30-day written notice of transfer/discharge
☐ Failure to provide notice of right to appeal to ADHS
☐ Discharge to unsafe location ("dumping")
☐ Bed-hold policy not honored after hospitalization (42 C.F.R. § 483.15(d))

H. Quality of Care

☐ Pressure ulcers / decubitus (42 C.F.R. § 483.25(b)(1))
☐ Falls without adequate assessment / interventions (42 C.F.R. § 483.25(d))
☐ Significant unexplained weight loss / dehydration / malnutrition (42 C.F.R. § 483.25(g))
☐ Medication errors, omissions, unnecessary medication (42 C.F.R. § 483.45)
☐ Inadequate infection control (42 C.F.R. § 483.80)
☐ Elopement / wandering injury (42 C.F.R. § 483.25(d))
☐ Failure to provide ADL care (bathing, toileting, grooming) (42 C.F.R. § 483.24)
☐ Inadequate staffing / unanswered call lights (42 C.F.R. § 483.35)

I. Abuse, Neglect, Exploitation

☐ Physical abuse by staff or another resident
☐ Sexual abuse / sexual assault
☐ Verbal or psychological abuse
☐ Neglect — pattern of denial of food, hydration, medication, hygiene
☐ Misappropriation of resident property / financial exploitation (A.R.S. § 46-456)
☐ Failure to investigate and report incidents within statutory deadlines (42 C.F.R. § 483.12(c))

Part V — Detailed Description of Concerns

A. What is happening / has happened

[________________________________________________________________]
[________________________________________________________________]
[________________________________________________________________]
[________________________________________________________________]

B. Specific incidents (chronological)

C. Resident's current condition

[________________________________________________________________]
[________________________________________________________________]

D. Imminent risk?

☐ Yes — immediate danger of serious harm or death
☐ Likely harm if not addressed within days
☐ Pattern of substandard care without immediate danger
☐ Past harm; resident now stable

Part VI — Internal Resolution Attempts

☐ Spoke with charge nurse on [__/__/____] — name: [____________] — outcome: [____________]
☐ Spoke with Director of Nursing on [__/__/____] — outcome: [____________]
☐ Spoke with Administrator on [__/__/____] — outcome: [____________]
☐ Submitted written grievance pursuant to facility grievance policy (42 C.F.R. § 483.10(j)) on [__/__/____]
☐ Care plan meeting requested / held on [__/__/____]
☐ Resident/family council notified
☐ No internal attempts (explain): [____________]

Part VII — Evidence Preserved

☐ Photographs (dates: [____________])
☐ Medical records / chart notes (dates: [____________])
☐ Medication Administration Record (MAR)
☐ Incident reports / 24-hour reports
☐ Care plan and MDS assessments
☐ Facility grievance log entries
☐ Correspondence (email, letters, texts)
☐ Bank/account statements (financial exploitation)
☐ Witness statements (names: [____________])
☐ Audio/video (note: A.R.S. § 13-3005 — Arizona is a one-party consent state for audio recording of one's own conversations; cameras in private rooms may require resident/roommate consent under facility policy and 42 C.F.R. § 483.10(h))

Part VIII — Relief Requested

☐ Onsite ADHS survey / complaint investigation under 42 C.F.R. § 488.332
☐ Immediate jeopardy determination and federal enforcement remedies (42 C.F.R. § 488.408): civil money penalty, denial of payment for new admissions, directed plan of correction, temporary management, termination from Medicare/Medicaid
☐ State licensure action under A.R.S. § 36-427: revocation, suspension, civil penalty, provisional license
☐ Cross-report to APS for vulnerable adult abuse/neglect/exploitation
☐ Cross-report to law enforcement and county attorney
☐ Cross-report to AHCCCS Office of Inspector General (Medicaid fraud)
☐ Long-Term Care Ombudsman advocacy and on-site visit
☐ Resident transfer to safe facility
☐ Restoration of resident's personal funds / property
☐ Rescission of involuntary discharge notice; reinstatement
☐ Other: [________________________________]

Part IX — Federal Enforcement Standards (42 U.S.C. § 1395i-3 / § 1396r)

A facility participating in Medicare or Medicaid must meet the requirements of the Nursing Home Reform Act, including providing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Failure to substantially comply may result in:

• Civil money penalties (per day or per instance) — 42 C.F.R. § 488.408, § 488.438
• Denial of payment for all new admissions — 42 C.F.R. § 488.417
• Temporary management — 42 C.F.R. § 488.415
• Directed plan of correction — 42 C.F.R. § 488.424
• State monitoring — 42 C.F.R. § 488.422
• Termination of provider agreement — 42 C.F.R. § 488.456

Part X — Coexisting Civil Remedies (Not Filed Here)

This complaint does not initiate civil litigation. The complainant/resident may also pursue:

• Civil action for endangerment/abuse/neglect of vulnerable adult — A.R.S. § 46-455 (2-year limitations from actual discovery; trebled damages and attorney's fees available)
• Financial exploitation civil remedy — A.R.S. § 46-456
• Common-law negligence, medical malpractice, wrongful death (A.R.S. § 12-542, § 12-611 et seq.)
• Breach of admission agreement / consumer fraud (A.R.S. § 44-1521 et seq.)

Part XI — Complainant Certification

I certify that the information in this complaint is true and correct to the best of my knowledge and belief. I am submitting this complaint in good faith and am aware that knowingly false reports may subject me to liability. I request that ADHS / the Long-Term Care Ombudsman investigate the matter and take appropriate enforcement action.

Signature: ____________________________

Printed name: ____________________________ Date: [__/__/____]

Part XII — Submission Instructions

Sources and References

• ADHS Long Term Care Complaint Portal: https://app3.azdhs.gov/PROD-AZHSComplaint-UI/Complaint/GetFAQ?bureau=LongTermCare
• ADHS Resident Rights Brochure (R9-10): https://www.azdhs.gov/documents/licensing/ltc-facilities/residents-rights.pdf
• AZ State Long-Term Care Ombudsman (DES): https://des.az.gov/LTCOP
• A.R.S. Title 36, Chapter 4 (Health Care Institutions): https://www.azleg.gov/arsDetail/?title=36
• A.A.C. R9-10 (Health Care Institution Licensing): https://apps.azsos.gov/public_services/Title_09/9-10.pdf
• 42 C.F.R. § 483 (federal nursing facility requirements): https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• 42 U.S.C. § 1395i-3 (Medicare SNF requirements): https://www.law.cornell.edu/uscode/text/42/1395i-3
• 42 U.S.C. § 1396r (Medicaid NF requirements): https://www.law.cornell.edu/uscode/text/42/1396r
• A.R.S. § 46-455 (vulnerable adult civil action): https://www.azleg.gov/ars/46/00455.htm
• A.R.S. § 46-456 (financial exploitation): https://www.azleg.gov/ars/46/00456.htm