Georgia Nursing Home Resident Complaint — DCH Healthcare Facility Regulation Division & Long-Term Care Ombudsman

COMPLAINT — VIOLATION OF NURSING HOME RESIDENT RIGHTS — STATE OF GEORGIA

TABLE OF CONTENTS

1. Caption — Concurrent Filing
2. Complainant and Resident Information
3. Facility Information
4. Statement of Resident Rights Asserted
5. Factual Allegations
6. Specific Violations Alleged
7. Internal Grievance History
8. Concurrent Filings and Referrals
9. Relief Requested
10. Anti-Retaliation Notice
11. Verification and Signature
12. Service / Submission Block
13. Georgia Practice Notes
14. Sources and References

1. CAPTION — CONCURRENT FILING

TO:

FROM: [COMPLAINANT NAME]

DATE: [__/__/____]

RE: Complaint of Violation of Resident Rights and Conditions of Care under O.C.G.A. § 31-8-100 et seq., Ga. Comp. R. & Regs. Ch. 111-8-50, and 42 C.F.R. § 483.10 et seq.

2. COMPLAINANT AND RESIDENT INFORMATION

Complainant (the individual filing this complaint):

Resident (the person on whose behalf the complaint is filed):

Confidentiality: ☐ The complainant requests confidentiality of identity to the extent permitted by law (Ombudsman: confidential under 42 U.S.C. § 3058g(d) absent resident consent; HFRD: complainant identity treated as confidential under O.C.G.A. § 31-2-8(g) where requested).

3. FACILITY INFORMATION

4. STATEMENT OF RESIDENT RIGHTS ASSERTED

This complaint invokes the rights guaranteed to the resident by:

• Georgia Bill of Rights for Residents of Long-Term Care Facilities, O.C.G.A. § 31-8-100 through § 31-8-127, including without limitation:
• § 31-8-103 (right to be free from mental and physical abuse, chemical and physical restraints)
• § 31-8-104 (right to medical care, choice of physician, informed consent)
• § 31-8-106 (privacy and confidentiality)
• § 31-8-107 (right to dignified treatment)
• § 31-8-108 (right to grievance procedure free from reprisal)
• § 31-8-110 (right to manage personal financial affairs)
• § 31-8-111 (right to retain personal property)
• § 31-8-112 (right to associate, correspond, and receive visitors)

• § 31-8-113 through § 31-8-115 (transfer / discharge protections)

• Georgia Long-Term Care Facility Rules, Ga. Comp. R. & Regs. Ch. 111-8-50 (Residents' Bill of Rights) and Ch. 111-8-56 (Nursing Homes).

• Federal Nursing Home Reform Act (OBRA '87), 42 U.S.C. § 1395i-3, § 1396r, and implementing regulations at 42 C.F.R. § 483.10 et seq., including:

• 42 C.F.R. § 483.10 (resident rights)
• 42 C.F.R. § 483.12 (freedom from abuse, neglect, exploitation)
• 42 C.F.R. § 483.15 (admission, transfer, discharge)
• 42 C.F.R. § 483.21 (comprehensive person-centered care planning)
• 42 C.F.R. § 483.24 (quality of life)
• 42 C.F.R. § 483.25 (quality of care — pressure ulcers, falls, medication, hydration, nutrition)
• 42 C.F.R. § 483.35 (nursing services / staffing)
• 42 C.F.R. § 483.45 (pharmacy and unnecessary drugs / antipsychotics)

5. FACTUAL ALLEGATIONS

5.1. The resident was admitted to the Facility on [__/__/____] for [level of care].

5.2. On or about [__/__/____], and continuing through [__/__/____], the Facility, by and through its agents and employees, engaged in the conduct set forth below.

5.3. [NARRATIVE — chronologically describe the events giving rise to the complaint, including dates, times, units / rooms, staff (by name or position where known), what was observed, what was documented in records, what statements were made, photographs taken, and the resident's medical or emotional response. Use additional pages as needed.]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

5.4. The resident sustained the following harm or risk of harm:

5.5. The Facility's conduct constitutes one or more violations as enumerated in Section 6.

6. SPECIFIC VIOLATIONS ALLEGED

(Check all that apply.)

Quality of Care and Safety:

☐ Failure to provide care consistent with the comprehensive care plan — 42 C.F.R. § 483.21; Ga. Comp. R. & Regs. § 111-8-56

☐ Pressure ulcer development or worsening absent unavoidable clinical condition — 42 C.F.R. § 483.25(b)

☐ Accident / fall with inadequate supervision or assistive devices — 42 C.F.R. § 483.25(d)

☐ Medication errors, including unnecessary or chemically restraining psychotropics — 42 C.F.R. § 483.45

☐ Inadequate hydration / nutrition — 42 C.F.R. § 483.25(g)

☐ Inadequate staffing — 42 C.F.R. § 483.35; Ga. Comp. R. & Regs. § 111-8-56

Abuse, Neglect, Exploitation:

☐ Physical, mental, sexual abuse, or involuntary seclusion — O.C.G.A. § 31-8-103; 42 C.F.R. § 483.12

☐ Neglect — failure to provide goods and services to avoid harm

☐ Exploitation — misappropriation of resident funds or property — O.C.G.A. § 31-8-110

☐ Use of physical or chemical restraint not authorized in writing by attending physician for medical symptoms — O.C.G.A. § 31-8-103; 42 C.F.R. § 483.10(e), § 483.12(a)(2)

Resident Dignity and Autonomy:

☐ Failure to provide privacy in treatment, communication, or personal care — O.C.G.A. § 31-8-106; 42 C.F.R. § 483.10(h)

☐ Restriction of visitation, correspondence, or telephone access — O.C.G.A. § 31-8-112

☐ Failure to permit choice of attending physician — O.C.G.A. § 31-8-104

☐ Failure to obtain informed consent — O.C.G.A. § 31-8-104

☐ Refusal to permit resident to manage personal financial affairs or to maintain personal property — O.C.G.A. §§ 31-8-110, 31-8-111

Transfer / Discharge:

☐ Involuntary transfer or discharge without statutory grounds, 30-day written notice, or right of appeal — O.C.G.A. §§ 31-8-113 to 31-8-115; 42 C.F.R. § 483.15

☐ Hospital "dumping" — refusal to readmit after hospitalization

Grievance and Reprisal:

☐ Retaliation for filing a grievance, contacting the Ombudsman, or exercising rights — O.C.G.A. § 31-8-108; 42 C.F.R. § 483.10(j)

☐ Failure to maintain or respond to grievance procedure

Records and Notices:

☐ Refusal of resident or representative access to medical / clinical records — 42 C.F.R. § 483.10(g)(2)

☐ Failure to provide written copy of resident rights at admission and post conspicuously

7. INTERNAL GRIEVANCE HISTORY

Pursuant to O.C.G.A. § 31-8-108 and 42 C.F.R. § 483.10(j), the resident / complainant has presented this matter to the Facility through its internal grievance procedure as follows:

☐ Facility's grievance officer name and contact: [__________]

☐ Resident has not yet filed an internal grievance because (explain): [__________]

8. CONCURRENT FILINGS AND REFERRALS

☐ Concurrent complaint filed with DCH-HFRD Complaint Intake, telephone 1-800-878-6442 / 404-657-5726 — confirmation: [__________]

☐ Concurrent complaint filed with Georgia State Long-Term Care Ombudsman, telephone 1-866-552-4464 (option 5) / 1-888-454-5826 — confirmation: [__________]

☐ Concurrent report to Adult Protective Services at 1-866-552-4464 (option 3) — confirmation: [__________]

☐ Concurrent report to local law enforcement — agency: [__________], report no.: [__________]

☐ Concurrent report to CMS Region IV (Atlanta) — for Medicare-certified facilities

☐ Concurrent notice to Medicaid Fraud Control Unit, Office of the Attorney General of Georgia, where exploitation / billing fraud is alleged

☐ Concurrent civil action filed / contemplated under O.C.G.A. § 31-8-126

9. RELIEF REQUESTED

Complainant respectfully requests:

A. Investigation. A prompt on-site investigation by DCH-HFRD pursuant to O.C.G.A. § 31-2-8 and Ga. Comp. R. & Regs. Ch. 111-8, and a separate Ombudsman investigation pursuant to O.C.G.A. § 31-8-50 et seq. and 42 U.S.C. § 3058g.

B. Immediate protective measures. Where indicated, a finding of immediate jeopardy under 42 C.F.R. § 488.301, imposition of denial of payment for new admissions, civil monetary penalties, directed plan of correction, temporary management, and/or appointment of a temporary manager.

C. Plan of Correction. Issuance of a Statement of Deficiencies (CMS-2567) and approval of a Plan of Correction with timely follow-up survey.

D. Restoration. Restoration of all rights, privileges, services, and personal property to the resident; reversal of any improper transfer or discharge.

E. Mediation / advocacy. Ombudsman mediation with the Facility to resolve grievances consistent with the resident's expressed wishes.

F. Anti-retaliation safeguards. Express written assurance from the Facility that no adverse action will be taken against the resident or complainant for filing this complaint.

G. Civil action notice. Reservation of all rights to private civil action under O.C.G.A. § 31-8-126 for damages, attorneys' fees, costs, and equitable relief.

H. Other relief as the agencies deem just and consistent with the resident's safety, dignity, and rights.

10. ANTI-RETALIATION NOTICE

Pursuant to O.C.G.A. § 31-8-108 and 42 C.F.R. § 483.10(j)(4), the Facility is on notice that retaliation against the resident or complainant for filing this grievance — including involuntary transfer, discharge, change in room or roommate, restriction of visitation, change in care plan, denial of services, harassment, or any adverse action — is prohibited and may result in further administrative, civil, and criminal action.

11. VERIFICATION AND SIGNATURE

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

[________________________________]

[COMPLAINANT NAME]

Date: [__/__/____]

(If filed by attorney:)

[LAW FIRM NAME]

By: [________________________________]

[ATTORNEY NAME], Georgia Bar No. [______]

Counsel for Complainant / Resident

[ADDRESS, PHONE, EMAIL]

12. SERVICE / SUBMISSION BLOCK

Filed and served upon:

1. Georgia Department of Community Health — Healthcare Facility Regulation Division
   Complaint Intake
   2 Peachtree Street NW, Atlanta, GA 30303
   Telephone: 1-800-878-6442 or 404-657-5726
   Online: https://dch.georgia.gov/divisionsoffices/facility-licensure/hfrd-file-complaint

2. Office of the State Long-Term Care Ombudsman
   Georgia Division of Aging Services
   2 Peachtree Street NW, Atlanta, GA 30303
   Telephone: 1-866-552-4464 (option 5) or 1-888-454-5826
   Online: https://www.georgiaombudsman.org

3. [FACILITY ADMINISTRATOR NAME]
   [FACILITY NAME]
   [ADDRESS]
   By ☐ U.S. Mail (certified, return receipt) ☐ Hand delivery ☐ Email ☐ Fax

Date of submission: [__/__/____]

[________________________________]

[COMPLAINANT / ATTORNEY SIGNATURE]

13. GEORGIA PRACTICE NOTES

• Dual track. A complaint to DCH-HFRD triggers a regulatory survey investigation with potential enforcement (civil monetary penalties, denial of payment, conditional license, suspension, revocation). A parallel complaint to the Long-Term Care Ombudsman triggers a resident-directed advocacy investigation. The two are complementary, not alternatives.
• Federal vs. state coverage. Federal NHRA / 42 C.F.R. § 483 protections apply only to Medicare- and Medicaid-certified nursing facilities. Personal Care Homes and Assisted Living Communities are governed primarily by Ga. Comp. R. & Regs. Ch. 111-8-62 (PCH) and Ch. 111-8-63 (ALC). Verify the precise facility type before invoking federal authority.
• Private right of action. O.C.G.A. § 31-8-126 expressly authorizes a civil action for damages, attorney's fees, and other relief on behalf of any person aggrieved by a violation of the Bill of Rights for Residents of Long-Term Care Facilities. The Georgia Court of Appeals has confirmed the action is independent of negligence-based theories.
• Statute of limitations. A § 31-8-126 action sounds in personal injury where bodily harm is alleged (two years under O.C.G.A. § 9-3-33) and may sound in contract or other theories (six years under § 9-3-24) depending on the right asserted. Confirm the operative limitations period for each theory before filing.
• Ombudsman confidentiality. Federal law (42 U.S.C. § 3058g(d)) and DAS policy require the Ombudsman to obtain resident consent before disclosing the resident's identity or sharing files. The Ombudsman's role is resident-directed; the resident (or representative for an incapacitated resident) controls disclosure and resolution.
• Survey records. DCH-HFRD survey results, Statements of Deficiencies (CMS-2567), and Plans of Correction are public records and obtainable via DCH HFRD records request and via Medicare's Care Compare.
• Immediate jeopardy. Where conditions create or likely will cause serious injury, harm, impairment, or death, request a finding of "immediate jeopardy" under 42 C.F.R. § 488.301; CMS-mandated remedies include up to $25,000+/day CMPs and termination of provider agreement.
• No mandatory exhaustion. A resident is not required to exhaust the facility's internal grievance procedure before contacting HFRD or the Ombudsman, although documentation of internal grievance attempts strengthens the complaint.
• Concurrent reporting. Where conduct involves abuse, neglect, or exploitation, also report to APS (1-866-552-4464) and law enforcement; reporting requirements under O.C.G.A. § 30-5-4 and § 31-8-80 et seq. are mandatory for many staff and providers.
• Discharge / transfer challenges. A nursing facility may not transfer or discharge a resident except for the six grounds enumerated in 42 C.F.R. § 483.15(c)(1) and O.C.G.A. § 31-8-113. Improper notice or pretextual reasons (e.g., refusal to readmit post-hospitalization, "behavior" without documented attempts at care planning) are common bases for complaint.

14. SOURCES AND REFERENCES

• DCH Healthcare Facility Regulation Division — File a Complaint: https://dch.georgia.gov/divisionsoffices/facility-licensure/hfrd-file-complaint
• DCH HFRD main page: https://dch.georgia.gov/divisionsoffices/hfrd
• Georgia Long-Term Care Ombudsman Program: https://www.georgiaombudsman.org
• LTC Ombudsman — Complaint Processing: https://www.georgiaombudsman.org/complaint-processing/
• O.C.G.A. Title 31 Ch. 8 Art. 5 (Bill of Rights for Residents of Long-Term Care Facilities, § 31-8-100 et seq.): https://law.justia.com/codes/georgia/title-31/chapter-8/article-5/
• Ga. Comp. R. & Regs. Ch. 111-8-50 (Residents' Bill of Rights): https://rules.sos.ga.gov/gac/111-8-50
• 42 C.F.R. Part 483 (Federal Requirements for Long-Term Care Facilities): https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• 42 U.S.C. § 1395i-3, § 1396r (Nursing Home Reform Act): https://www.law.cornell.edu/uscode/text/42/1396r
• 42 U.S.C. § 3058g (Long-Term Care Ombudsman Program — Older Americans Act): https://www.law.cornell.edu/uscode/text/42/3058g
• CMS Care Compare (Nursing Home survey results): https://www.medicare.gov/care-compare/
• DAS LTCO Policy Manual (PAMMS 5100): https://pamms.dhs.ga.gov/das/ltco/5100/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Statutory citations, federal regulations, and agency contact information change; verify the current DCH-HFRD complaint intake number, Ombudsman contact, and the operative version of O.C.G.A. § 31-8-100 et seq. before filing. An attorney licensed in Georgia must review and customize this template before use, particularly for litigation under O.C.G.A. § 31-8-126.