Kansas Nursing Home / Adult Care Home Resident Complaint — Long-Term Care Ombudsman & KDADS

KANSAS NURSING HOME / ADULT CARE HOME RESIDENT COMPLAINT

TABLE OF CONTENTS

1. Complaint Cover Sheet
2. Complainant Information
3. Resident Information
4. Facility Information
5. Statement of Resident Rights Violated
6. Factual Allegations
7. Harm to Resident
8. Internal Grievance and Facility Response
9. Requested Relief and Remedies
10. Confidentiality and Consent (Ombudsman)
11. Submission and Routing
12. Complainant Certification
13. Kansas Practice Notes
14. Sources and References

1. COMPLAINT COVER SHEET

TO: ☐ Kansas Office of the State Long-Term Care Ombudsman ☐ Kansas Department for Aging and Disability Services (KDADS) Complaint Hotline ☐ Kansas Department of Health and Environment (KDHE) ☐ Local Law Enforcement ☐ Other: [________________________________]

FROM: [________________________________] (Complainant)

RE: Complaint regarding the care, treatment, or rights of [RESIDENT NAME] at [FACILITY NAME]

DATE: [__/__/____]

URGENT? ☐ Yes — immediate risk of harm ☐ No

2. COMPLAINANT INFORMATION

2.1. Name: [________________________________]

2.2. Relationship to Resident:

• ☐ Resident (self)
• ☐ Spouse
• ☐ Adult child / family member — relationship: [________________________________]
• ☐ Power of Attorney — type (health care / financial / general): [________________________________]
• ☐ Guardian / conservator — court / case no.: [________________________________]
• ☐ Friend / visitor
• ☐ Facility staff (current / former)
• ☐ Other: [________________________________]

2.3. Address: [________________________________]

2.4. Telephone: [________________________________]

2.5. Email: [________________________________]

2.6. Preferred method of contact: ☐ Phone ☐ Email ☐ Mail

2.7. Anonymous? ☐ Yes (note: anonymity may limit follow-up; the Ombudsman and KDADS accept anonymous complaints)

3. RESIDENT INFORMATION

3.1. Resident Name: [________________________________]

3.2. Date of Birth / Age: [__/__/____] / [______]

3.3. Date of Admission to Facility: [__/__/____]

3.4. Room / Unit: [________________________________]

3.5. Payor Source:

• ☐ Medicare (Part A skilled stay)
• ☐ Medicaid (KanCare / FE Waiver)
• ☐ Private pay
• ☐ Long-term care insurance
• ☐ VA
• ☐ Other: [________________________________]

3.6. Diagnoses / conditions relevant to the complaint: [________________________________]

3.7. Communication / cognitive limitations (if any): [________________________________]

3.8. Known authorized representatives (POA / guardian / surrogate): [________________________________]

4. FACILITY INFORMATION

4.1. Facility Legal Name: [________________________________]

4.2. Doing Business As (DBA): [________________________________]

4.3. Facility Type (check one or more):

• ☐ Skilled Nursing Facility (SNF)
• ☐ Nursing Facility (NF — Medicaid)
• ☐ Assisted Living Facility (ALF)
• ☐ Residential Health Care Facility (RHCF)
• ☐ Home Plus
• ☐ Nursing Facility for Mental Health (NFMH)
• ☐ Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID)
• ☐ Adult Day Care
• ☐ Hospital long-term care unit

4.4. Address: [________________________________]

4.5. Telephone: [________________________________]

4.6. Administrator: [________________________________]

4.7. Director of Nursing: [________________________________]

4.8. Owner / Operator / Parent Company: [________________________________]

4.9. State License No. (if known): [________________________________]

4.10. CMS Provider No. (CCN, if known): [________________________________]

5. STATEMENT OF RESIDENT RIGHTS VIOLATED

The Complainant alleges violations of the following resident rights (check all that apply). Federal citations are to 42 C.F.R. Part 483; state citations are to K.A.R. 28-39-147 and the Kansas adult care home statutes.

Federal Resident Rights — 42 C.F.R. § 483.10:

• ☐ Right to dignity, respect, and self-determination — § 483.10(a)
• ☐ Right to be informed and to participate in own care planning — § 483.10(c)
• ☐ Right to choice of attending physician — § 483.10(d)
• ☐ Right to privacy and confidentiality of records — § 483.10(h)
• ☐ Right to voice grievances without reprisal — § 483.10(j)
• ☐ Right to refuse medication, treatment, or transfer/discharge — § 483.10(c)(6), § 483.15
• ☐ Right to be free from physical or chemical restraints not required to treat medical symptoms — § 483.10(e), § 483.12(a)(2)
• ☐ Right to access visitors of resident's choosing — § 483.10(f)(4)
• ☐ Right to manage personal financial affairs — § 483.10(f)(10)
• ☐ Right to be informed of facility transfer/discharge with statutory notice — § 483.15(c)
• ☐ Right to access ombudsman, advocates, and federal/state inspection results — § 483.10(g)(4), (i)

Federal Abuse / Neglect Protections — 42 C.F.R. § 483.12:

• ☐ Freedom from physical, verbal, sexual, or mental abuse — § 483.12
• ☐ Freedom from corporal punishment and involuntary seclusion — § 483.12
• ☐ Freedom from neglect — § 483.12
• ☐ Freedom from misappropriation of resident property — § 483.12

Federal Quality of Care — 42 C.F.R. §§ 483.24, 483.25, 483.40, 483.45:

• ☐ Failure to provide ADL care necessary to attain or maintain highest practicable well-being
• ☐ Pressure ulcers / skin breakdown
• ☐ Falls / inadequate fall prevention
• ☐ Medication errors / inadequate pharmacy review
• ☐ Inadequate nutrition / hydration / weight loss
• ☐ Inadequate behavioral / mental health services
• ☐ Inadequate infection control

Kansas Resident Rights — K.A.R. 28-39-147 / K.S.A. § 39-1401 et seq.:

• ☐ Failure to provide written statement of resident rights upon admission
• ☐ Failure to ensure right to inspect and copy clinical records
• ☐ Failure to ensure right to reasonable, private telephone access
• ☐ Failure to ensure privacy in personal care, communications, and visits
• ☐ Failure to allow retention and use of personal possessions
• ☐ Improper discharge / transfer notice
• ☐ Improper or undocumented use of restraints

Kansas Reporting Failures — K.S.A. § 39-1402:

• ☐ Failure of staff to report suspected abuse, neglect, or exploitation
• ☐ Retaliation against reporter (resident, staff, or family)

6. FACTUAL ALLEGATIONS

State, in chronological order, the specific facts giving rise to the complaint. Include dates, times, names of involved staff, observations, statements, and physical or documentary evidence.

6.1. [________________________________________________________________]

6.2. [________________________________________________________________]

6.3. [________________________________________________________________]

6.4. [________________________________________________________________]

6.5. [________________________________________________________________]

6.6. [________________________________________________________________]

6.7. [________________________________________________________________]

7. HARM TO RESIDENT

7.1. Physical injury: ☐ None known ☐ Minor ☐ Moderate ☐ Serious ☐ Death

7.2. Description of physical injury / clinical findings: [________________________________]

7.3. Medical treatment received: [________________________________]

7.4. Mental / emotional harm: [________________________________]

7.5. Financial harm: $[__________] Description: [________________________________]

7.6. Hospitalization or ER visit related to the complaint: ☐ Yes ☐ No Date / facility: [________________________________]

7.7. Death: ☐ Yes ☐ No Date / cause as stated on certificate: [________________________________]

8. INTERNAL GRIEVANCE AND FACILITY RESPONSE

8.1. Was the complaint first raised internally with the facility? ☐ Yes ☐ No

8.2. Date raised: [__/__/____]

8.3. Person(s) at facility contacted:

8.4. Did the facility provide a written response? ☐ Yes ☐ No (attach copy)

8.5. Was the matter resolved? ☐ Yes ☐ No ☐ Partially

8.6. Has the resident or Complainant experienced any retaliation? ☐ Yes ☐ No Describe: [________________________________]

9. REQUESTED RELIEF AND REMEDIES

The Complainant requests the following (check all that apply):

From the Long-Term Care Ombudsman:

• ☐ Resident-directed advocacy and complaint resolution
• ☐ On-site visit to the resident
• ☐ Mediation between resident/family and facility
• ☐ Information about resident rights and care options
• ☐ Coordination with regulators and other agencies

From KDADS / KDHE (regulatory):

• ☐ Investigation under 42 C.F.R. Part 488 / Kansas survey authority
• ☐ Unannounced complaint survey
• ☐ Citation and Statement of Deficiencies (Form CMS-2567)
• ☐ Civil monetary penalties (CMPs)
• ☐ Denial of payment for new admissions
• ☐ Directed plan of correction
• ☐ Temporary management / receivership
• ☐ License revocation / nonrenewal
• ☐ Referral to Medicaid Fraud Control Unit (MFCU) of the Kansas Attorney General
• ☐ Referral to professional licensing board(s)

From Law Enforcement / Prosecutor (if criminal):

• ☐ Investigation under K.S.A. § 21-5417 (mistreatment of a dependent adult or elder person)
• ☐ Investigation of theft / financial crime (K.S.A. § 21-5801 et seq.)
• ☐ Other criminal investigation: [________________________________]

Resident-Specific Relief:

• ☐ Immediate cessation of the alleged conduct
• ☐ Reassignment of staff member
• ☐ Updated care plan and assessment
• ☐ Restoration of personal property or funds
• ☐ Rescission of improper discharge / transfer
• ☐ Hospital evaluation / specialist consultation
• ☐ Other: [________________________________]

10. CONFIDENTIALITY AND CONSENT (OMBUDSMAN)

The Ombudsman program is resident-directed and confidential under 42 U.S.C. § 3058g(d) and K.S.A. § 75-7301 et seq. The Ombudsman will not disclose the resident's identity, the Complainant's identity, or the contents of this complaint without written consent of the resident (or, where the resident lacks capacity, the resident's legal representative).

10.1. Resident / Representative Consent: I, the resident or the resident's legal representative, consent to the following disclosures by the Ombudsman:

• ☐ Disclose resident identity to facility administration in connection with investigation
• ☐ Disclose resident identity to KDADS / KDHE
• ☐ Disclose resident identity to law enforcement
• ☐ Disclose resident identity to KanCare MCO and discharge planners
• ☐ Disclose Complainant identity to facility
• ☐ Withhold resident identity (process complaint as anonymous)

Resident / Representative signature: [________________________________]

Print name and capacity: [________________________________]

Date: [__/__/____]

11. SUBMISSION AND ROUTING

11.1. Kansas Office of the State Long-Term Care Ombudsman:

• Telephone: 1-877-662-8362
• Web complaint: https://www.ombudsman.ks.gov/file-a-complaint/file-a-complaint
• Mail: Office of the State Long-Term Care Ombudsman, Topeka, KS

11.2. KDADS Complaint Hotline (regulator):

• Telephone: 1-800-842-0078
• Fax: 785-296-0256
• Email: [email protected]
• In-person appointment: by request via the email address above

11.3. KDHE (where applicable to resident health/medical regulation): https://www.kdhe.ks.gov/

11.4. Adult Protective Services / Abuse, Neglect, Exploitation:

• Kansas Protection Report Center (24/7): 1-800-922-5330
• DCF KIPS web intake: https://www.dcf.ks.gov/services/pps/pages/kips/kipswebintake.aspx

11.5. Medicare / CMS (federally certified facilities): 1-800-MEDICARE (1-800-633-4227)

11.6. Kansas Attorney General — Medicaid Fraud Control Unit: https://www.ag.ks.gov/

11.7. Method(s) of submission used:

• ☐ Telephone — agency / staff / time: [________________________________]
• ☐ Online portal — confirmation number: [________________________________]
• ☐ Fax — confirmation: [________________________________]
• ☐ Email — recipient: [________________________________]
• ☐ Certified mail — tracking number: [________________________________]

11.8. Date of submission: [__/__/____]

12. COMPLAINANT CERTIFICATION

I, [COMPLAINANT NAME], certify the following:

a. The information set forth in this complaint is true and correct to the best of my knowledge and belief;

b. I am submitting this complaint in good faith for the protection and welfare of the resident;

c. To the extent I am a "mandatory reporter" under K.S.A. § 39-1402 or § 39-1431, I have made or am making the corresponding statutory report to the Kansas Protection Report Center (1-800-922-5330) and to KDADS, in addition to filing this complaint;

d. I understand that good-faith reporters are immune from civil and criminal liability under K.S.A. § 39-1404 and § 39-1431(f);

e. I authorize the Ombudsman, KDADS, KDHE, DCF, law enforcement, and the Kansas Attorney General — to the extent consistent with the consent provisions of Section 10 — to share information necessary to investigate and resolve this complaint;

f. I will cooperate with the investigating agencies and provide additional information upon request;

g. I understand that filing this complaint does NOT toll any statute of limitations applicable to civil claims and that I should consult an attorney promptly if I wish to preserve civil remedies.

Complainant signature: [________________________________]

Print name: [________________________________]

Date: [__/__/____]

13. KANSAS PRACTICE NOTES

• Two complaint pathways. The Long-Term Care Ombudsman is an independent advocate operating under the resident's direction; the Ombudsman's role is resident-empowerment, mediation, and information. KDADS is the licensing regulator with enforcement authority — survey, citation, civil monetary penalties, denial of payment, directed plans of correction, temporary management, and license revocation. File with both for serious complaints.
• Federal NHRA. All Medicare- and Medicaid-certified nursing facilities in Kansas must satisfy 42 U.S.C. §§ 1395i-3 / 1396r and the implementing regulations at 42 C.F.R. Part 483. Federal resident rights at § 483.10 and abuse / neglect protections at § 483.12 are independently enforceable through the state survey agency (KDADS) under 42 C.F.R. Part 488.
• Kansas adult care home framework. K.S.A. § 39-923 defines the categories of "adult care home" — including skilled nursing, NF, ALF, RHCF, Home Plus, NFMH, ICF/IID, and adult day care. K.A.R. 28-39-1 et seq. supplies operating standards; K.A.R. 28-39-147 codifies resident rights for the Kansas-only categories (assisted living, Home Plus, RHCF, etc.) that are not directly governed by the federal NHRA.
• Reporting framework. K.S.A. § 39-1401 et seq. governs reporting of abuse, neglect, or exploitation of facility residents. Mandatory reporters must report immediately; knowing failure is a class B misdemeanor under § 39-1402(d). Good-faith reporters enjoy immunity under § 39-1404.
• Improper discharge/transfer. Federal law (42 C.F.R. § 483.15) requires written 30-day notice (with limited exceptions for emergencies, danger to others, or non-payment) and a statement of the resident's right to appeal to the State Fair Hearing process. Improper discharge / "dumping" is a recurring complaint type and is independently citable.
• Retaliation. Retaliation against residents or family members for filing complaints is prohibited under 42 C.F.R. § 483.10(j) and Kansas regulation. Document and report any retaliation as a separate violation.
• Civil claims. A complaint to the Ombudsman or KDADS is NOT a substitute for civil litigation and does NOT toll the limitations period. Personal-injury actions in Kansas are generally subject to a two-year limitations period under K.S.A. § 60-513; wrongful-death actions are also two years under K.S.A. § 60-513; medical-malpractice claims (if the facility's medical professionals are involved) follow K.S.A. § 60-513 with a four-year repose. Consult counsel promptly.
• Records access. Residents and their authorized representatives have a federal right under 42 C.F.R. § 483.10(g)(2) to access clinical records within 24 hours and to receive copies within two working days. Use this right to develop the factual record before the facility "cleans up" documentation.
• Coordination with KanCare MCO. For Medicaid recipients, coordinate with the resident's KanCare MCO (Aetna Better Health of Kansas, Sunflower Health Plan, or UnitedHealthcare Community Plan); the MCO has its own grievance process and care-coordination obligations.
• Federal CMS reporting. For deficient federally-certified facilities, complaints can also be filed with CMS Region 7 (Kansas City) and through Medicare.gov's Care Compare, which publishes inspection results, deficiencies, fines, and staffing data.

14. SOURCES AND REFERENCES

• Kansas Office of the State Long-Term Care Ombudsman — https://www.ombudsman.ks.gov/
• Ombudsman File a Complaint — https://www.ombudsman.ks.gov/file-a-complaint/file-a-complaint
• Ombudsman Resident Rights — https://www.ombudsman.ks.gov/helpful-resources/issues-of-interest/resident-rights
• KDADS Hotlines — https://www.kdads.ks.gov/media-center/hotlines
• KDADS Complaint Hotline — 1-800-842-0078 / [email protected]
• Kansas Department of Health and Environment — https://www.kdhe.ks.gov/
• DCF Adult Protective Services — https://www.dcf.ks.gov/services/PPS/Pages/ReportAdultAbuseNeglect.aspx
• K.S.A. Chapter 39, Article 9 (Adult Care Homes) — https://ksrevisor.gov/statutes/chapters/ch39/
• K.S.A. § 39-923 (definitions) — https://ksrevisor.gov/statutes/chapters/ch39/039_009_0023.html
• K.S.A. § 39-1401 et seq. (reporting; resident protections) — https://ksrevisor.gov/
• K.A.R. 28-39-147 (resident rights regulation) — https://www.law.cornell.edu/regulations/kansas/K-A-R-28-39-147
• 42 C.F.R. Part 483 (federal long-term care 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/
• 42 C.F.R. § 483.12 (Freedom from abuse, neglect, exploitation) — https://www.ecfr.gov/
• Older Americans Act — Long-Term Care Ombudsman Program, 42 U.S.C. § 3058g
• CMS Care Compare (Medicare) — https://www.medicare.gov/care-compare/
• Kansas Attorney General Medicaid Fraud Control Unit — https://www.ag.ks.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Filing a complaint with the Long-Term Care Ombudsman or KDADS does not toll any statute of limitations applicable to civil claims. A Kansas-licensed attorney should review the facts and timing of any potential civil action — particularly negligence, wrongful death, statutory bad-faith, and related tort claims — before relying on the regulatory complaint process alone.