Nursing Home Resident Complaint — Colorado Long-Term Care Ombudsman / CDPHE

NURSING HOME RESIDENT COMPLAINT — COLORADO

TABLE OF CONTENTS

1. Cover Page and Recipients
2. Resident Information
3. Complainant Information and Authority
4. Facility Information
5. Statement of Resident Rights at Issue
6. Factual Allegations
7. Harm and Damages
8. Prior Grievance Procedure / Internal Steps
9. Requested Relief / Enforcement Action
10. Anti-Retaliation Demand
11. Verification, Authorizations, and Signature
12. Distribution and Service List
13. Colorado Practice Notes
14. Sources and References

1. COVER PAGE AND RECIPIENTS

Date: [__/__/____]

Re: Complaint Concerning [FACILITY NAME] — Resident [RESIDENT INITIALS], Room [____]

2. RESIDENT INFORMATION

3. COMPLAINANT INFORMATION AND AUTHORITY

3.1. Authority to File. Check all that apply (per C.R.S. § 25-1-120(1)(t) and 42 C.F.R. § 483.10(j)):

• ☐ Complainant is the resident.
• ☐ Complainant is a member of the residents' advisory council.
• ☐ Complainant is the resident's family member, guardian, conservator, agent under power of attorney, or health-care agent.
• ☐ Complainant is a friend or other person filing on the resident's behalf, regardless of the resident's consent (as expressly permitted by § 25-1-120(1)(t) for grievances about treatment, conditions, or violation of rights of any other resident).
• ☐ Complainant is a Long-Term Care Ombudsman.
• ☐ Complainant is a mandatory reporter under C.R.S. § 18-6.5-108 (parallel APS report being filed).

3.2. Confidentiality Request.

• ☐ Complainant requests confidentiality. Resident and complainant identity are protected against disclosure to the facility absent consent. 42 C.F.R. § 483.10(j)(2); 42 U.S.C. § 3058g(d).
• ☐ Complainant does not request confidentiality.

4. FACILITY INFORMATION

5. STATEMENT OF RESIDENT RIGHTS AT ISSUE

The complainant alleges that the facility violated, and is continuing to violate, one or more of the following resident rights. Check all that apply.

Federal — 42 C.F.R. Part 483 (Nursing Home Reform Act):

• ☐ § 483.10(a) — Right to dignity and self-determination.
• ☐ § 483.10(b) — Right to exercise rights free from interference.
• ☐ § 483.10(c) — Right to be informed; participation in care planning.
• ☐ § 483.10(e) — Right to privacy and confidentiality.
• ☐ § 483.10(f) — Right to make choices (activities, schedules, health care, roommate).
• ☐ § 483.10(g) — Right to information; access to records.
• ☐ § 483.10(h) — Right to privacy of personal and clinical records.
• ☐ § 483.10(i) — Safe environment.
• ☐ § 483.10(j) — Grievances; right to be free from retaliation.
• ☐ § 483.12 — Freedom from abuse, neglect, exploitation; reporting and investigation.
• ☐ § 483.15 — Admission, transfer, and discharge rights.
• ☐ § 483.21 — Comprehensive person-centered care planning.
• ☐ § 483.24 — Quality of life (ADLs, mobility, activities).
• ☐ § 483.25 — Quality of care (pressure ulcers, falls, hydration, nutrition, medication, pain).
• ☐ § 483.30 — Physician services.
• ☐ § 483.35 — Nursing services / sufficient staffing.
• ☐ § 483.40 — Behavioral health services.
• ☐ § 483.45 — Pharmacy services / unnecessary drugs / chemical restraints.
• ☐ § 483.55 — Dental services.
• ☐ § 483.70 — Administration / governance.
• ☐ § 483.95 — Training requirements.

Colorado — C.R.S. § 25-1-120 (Nursing Facilities — Rights of Patients):

• ☐ Right to civil and religious liberties (§ 25-1-120(1)(a)).
• ☐ Right to private and unrestricted communication (§ 25-1-120(1)(b)).
• ☐ Right to present grievances to staff, administrator, government officials, or any other person, without fear of reprisal (§ 25-1-120(1)(c), (1)(t)).
• ☐ Right to manage personal financial affairs (§ 25-1-120(1)(d)).
• ☐ Right to be free from mental and physical abuse (§ 25-1-120(1)(e)).
• ☐ Right to be free from chemical and physical restraints except as authorized in writing by a physician (§ 25-1-120(1)(f)).
• ☐ Right to confidentiality of medical records (§ 25-1-120(1)(g)).
• ☐ Right to be treated with consideration, respect, and full recognition of dignity and individuality (§ 25-1-120(1)(h)).
• ☐ Right to refuse experimental research (§ 25-1-120(1)(i)).
• ☐ Right to be transferred or discharged only for medical reasons, welfare, non-payment, or facility cessation (§ 25-1-120(1)(j)).
• ☐ Right to wear personal clothing and retain personal possessions (§ 25-1-120(1)(k)).
• ☐ Right to participate in residents' advisory council (§ 25-1-120(1)(l)).
• ☐ Right to be informed in writing of services available, including charges (§ 25-1-120).

6. FACTUAL ALLEGATIONS

6.1. Provide a chronological narrative. Identify each incident with date, time, location within the facility, persons involved, what occurred, and how the complainant learned of it.

[NARRATIVE — ATTACH ADDITIONAL PAGES AS NEEDED]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

6.2. Incident Log.

6.3. Witnesses.

6.4. Evidence Attached.

• ☐ Photographs of injuries / pressure ulcers / room conditions
• ☐ Medical records (face sheet, MDS, care plan, MAR, nursing notes, physician orders)
• ☐ Hospital records / ER discharge summary
• ☐ Incident reports / grievance log entries
• ☐ Written correspondence with facility (letters, emails, texts)
• ☐ Audio / video / photographic recordings (consistent with C.R.S. § 25-1-120.5 if "Sade's Law"-style monitoring)
• ☐ Death certificate / autopsy report (if applicable)
• ☐ Other: [________________________________]

7. HARM AND DAMAGES

Describe the resident's physical, emotional, financial, or dignitary harm:

8. PRIOR GRIEVANCE PROCEDURE / INTERNAL STEPS

Pursuant to 42 C.F.R. § 483.10(j) and C.R.S. § 25-1-120(1)(t), the facility must have a written grievance procedure and a designated Grievance Official.

• ☐ Facility failed to provide a written grievance decision within the time required by 42 C.F.R. § 483.10(j)(4) (typically a reasonable period; many states require 7–14 days).
• ☐ Facility's grievance response was unresponsive or did not remediate the violation.
• ☐ Complainant elected to bypass internal grievance because the harm is ongoing or imminent.

9. REQUESTED RELIEF / ENFORCEMENT ACTION

Complainant requests that the receiving agencies, jointly and severally:

• ☐ Initiate an unannounced complaint survey of the facility under 42 C.F.R. § 488.332 and 6 C.C.R. 1011-1, Chapter V.
• ☐ Cite the facility for federal and state deficiencies and require a Plan of Correction.
• ☐ Impose civil money penalties under C.R.S. § 25-1-107.5 (between $100 and $10,000 per day; elevated penalties for life-threatening or serious-harm violations) and 42 C.F.R. §§ 488.408, 488.438. Penalties collected pursuant to C.R.S. § 25.5-6-205 are deposited in the nursing facility cash fund.
• ☐ Impose denial of payment for new admissions (42 C.F.R. § 488.417).
• ☐ Appoint a temporary manager or impose directed in-service training (42 C.F.R. § 488.406).
• ☐ Initiate license revocation or suspension under C.R.S. § 25-1.5-103 and 6 C.C.R. 1011-1 if conditions warrant.
• ☐ Refer for criminal investigation under C.R.S. § 18-6.5-101 et seq. (Wrongs to At-Risk Persons) and § 18-6.5-108 (mandatory reporting; penalties).
• ☐ Open an Adult Protective Services investigation under C.R.S. § 26-3.1-102.
• ☐ Direct immediate corrective action to abate ongoing harm (e.g., wound care protocol, fall-prevention plan, additional staffing, medication review).
• ☐ Long-Term Care Ombudsman advocacy to resolve the resident's specific complaint and to monitor the facility's response.
• ☐ Notice to CMS Region VIII for federal certification action.
• ☐ Other: [________________________________]

10. ANTI-RETALIATION DEMAND

Pursuant to 42 C.F.R. § 483.10(j)(4) and C.R.S. § 25-1-120(1)(t), the facility may not discharge, transfer, or otherwise retaliate against a resident or complainant for exercising the right to voice grievances. Complainant demands that the facility:

1. Take no adverse action against the resident, including involuntary transfer or discharge, change of room or roommate, restriction of visitors, or modification of care plan, in response to this complaint.
2. Document the complaint in the resident's record without negative characterization.
3. Permit unrestricted communication between the resident and the Long-Term Care Ombudsman, family, counsel, and regulators.

The complainant requests the receiving agencies monitor the facility's response and treat any retaliatory action as an aggravating factor in any enforcement determination.

11. VERIFICATION, AUTHORIZATIONS, AND SIGNATURE

I declare under penalty of perjury under the laws of the State of Colorado that the foregoing is true and correct to the best of my knowledge and belief.

11.1. HIPAA / Records Authorization. To the extent the complainant has authority to authorize disclosure (as resident, agent under HIPAA-compliant authorization, personal representative, guardian, or health-care agent), the complainant authorizes the receiving agencies to obtain the resident's medical records, MDS data, billing records, incident reports, and other facility records relevant to the investigation. (Attach signed HIPAA authorization where required.)

11.2. Reservation of Rights. This complaint is administrative in nature. The complainant and the resident reserve all rights to pursue civil remedies, including but not limited to negligence, gross negligence, willful and wanton conduct, fraud, breach of contract, breach of fiduciary duty, statutory claims under C.R.S. § 25-1-120, wrongful death (C.R.S. § 13-21-202), and survivorship actions (C.R.S. § 13-20-101). Statutes of limitations are short — including the two-year limitation period for most personal injury actions in Colorado (C.R.S. § 13-80-102) — and run independently of administrative proceedings.

Complainant Signature: [________________________________]

Print Name: [________________________________]

Capacity: [________________________________]

Date: [__/__/____]

Resident Signature (if able and willing): [________________________________]

Print Name: [________________________________]

Date: [__/__/____]

12. DISTRIBUTION AND SERVICE LIST

13. COLORADO PRACTICE NOTES

• Two parallel statutory frameworks. Federal NHRA (Medicare 42 U.S.C. § 1395i-3 and Medicaid 42 U.S.C. § 1396r) and CMS Part 483 set baseline rights. Colorado adds independent statutory rights under C.R.S. § 25-1-120 enforceable by CDPHE inspection and civil penalty. Always cite both.
• Civil money penalties. C.R.S. § 25-1-107.5 authorizes penalties of $100 to $10,000 per day per deficiency. Penalties for "Class I" (immediate jeopardy) deficiencies must be assessed; lesser deficiencies are discretionary. C.R.S. § 25.5-6-205 directs penalty collection into the nursing facility cash fund used to support resident protection activities.
• Section 25-1-124. Section 25-1-124 of Title 25 addresses health-facility reporting and event-reporting obligations for licensed facilities. Cite the current text as published in the Colorado Revised Statutes; § 25-1-107.5 is the primary civil-money-penalty authority for nursing facility deficiencies, and § 25.5-6-205 governs collection.
• Residents' advisory council. C.R.S. § 25-1-120 requires every SNF/ICF to establish a residents' advisory council of at least five resident members, meeting monthly with the administrator and a staff representative. Complaint patterns should be reviewed at council meetings.
• Ombudsman confidentiality. Under the Older Americans Act (42 U.S.C. § 3058g(d)) and 45 C.F.R. § 1324.11, Ombudsman files are confidential and the resident's identity cannot be disclosed without consent.
• Discharge and transfer protections. A facility may transfer or discharge only for the limited reasons in 42 C.F.R. § 483.15(c) and C.R.S. § 25-1-120(1)(j). Notice and appeal rights apply; appeals go to the Office of Administrative Courts.
• At-risk adult overlap. Many quality-of-care complaints simultaneously implicate APS jurisdiction under C.R.S. § 26-3.1-102 and criminal mandatory reporting under § 18-6.5-108. File parallel reports to the county APS unit and law enforcement when allegations rise to mistreatment.
• Civil litigation. Colorado follows a two-year statute of limitations for negligence and most personal injury (C.R.S. § 13-80-102); medical malpractice claims are governed by C.R.S. § 13-80-102.5 (two years, with discovery rule and three-year repose). Colorado also caps non-economic damages under C.R.S. § 13-21-102.5; consult counsel before relying on any damage projection.
• Pre-dispute arbitration clauses. CMS rules at 42 C.F.R. § 483.70(n) regulate facility arbitration agreements. Verify whether the resident signed a binding arbitration agreement and whether it complies with current federal rules.

14. SOURCES AND REFERENCES

• 42 U.S.C. § 1395i-3 (Medicare NHRA) — https://www.govinfo.gov/
• 42 U.S.C. § 1396r (Medicaid NHRA)
• 42 C.F.R. Part 483 — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• C.R.S. § 25-1-120 — https://codes.findlaw.com/co/title-25-health/co-rev-st-sect-25-1-120/
• C.R.S. § 25-1-107.5 (civil penalties for nursing facility deficiencies) — https://codes.findlaw.com/co/title-25-health/co-rev-st-sect-25-1-107-5.html
• C.R.S. § 25.5-6-205 (penalty collection / cash fund) — https://law.justia.com/codes/colorado/title-25-5/article-6/part-2/section-25-5-6-205/
• C.R.S. § 26-11.5-101 et seq. (State Long-Term Care Ombudsman Program)
• 6 C.C.R. 1011-1, Chapter V (CDPHE nursing care facility regulations) — https://www.sos.state.co.us/CCR/
• CDPHE Health Facility Complaints — 1-800-886-7689 — https://cdphe.colorado.gov/health-facility-complaints
• Colorado State Long-Term Care Ombudsman — 1-800-288-1376 — https://www.coombudsman.org/
• Colorado Senior Residents' Rights — https://www.coombudsman.org/resident-rights/
• CMS Region VIII (Denver) — https://www.cms.gov/About-CMS/Agency-Information/RegionalOffices/Region8
• 45 C.F.R. Part 1324 (LTC Ombudsman regulations)
• HCPF Long-Term Services and Supports — https://hcpf.colorado.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Statutory citations and regulatory cross-references change. Verify the current text of C.R.S. § 25-1-120, § 25-1-107.5, § 25-1-124, § 25.5-6-205, and 42 C.F.R. Part 483 before filing. An attorney licensed in Colorado must review and customize this complaint before use in any judicial, administrative, or licensure proceeding.