Montana Nursing Home Resident Complaint — Long-Term Care Ombudsman and DPHHS Quality Assurance Division

MONTANA NURSING HOME RESIDENT COMPLAINT

Long-Term Care Ombudsman / DPHHS Quality Assurance Division

TABLE OF CONTENTS

1. Filing Cover Sheet
2. Complainant Information
3. Resident Information
4. Facility Information
5. Statement of Rights Violated
6. Factual Allegations
7. Specific Conduct and Statutory Violations
8. Resident Consent and Confidentiality
9. Remedies and Relief Sought
10. Anti-Retaliation Notice
11. Verification and Signature
12. Service / Filing Distribution
13. Montana Practice Notes
14. Sources and References

1. FILING COVER SHEET

2. COMPLAINANT INFORMATION

2.1. Name: [________________________________]

2.2. Relationship to Resident: ☐ Self (resident) ☐ Spouse ☐ Adult child ☐ Parent ☐ Guardian / Conservator ☐ POA ☐ Friend ☐ Facility staff ☐ Other: [__________]

2.3. Address: [________________________________]

2.4. Phone (day): [________________________________]

2.5. Phone (evening / mobile): [________________________________]

2.6. Email: [________________________________]

2.7. Preferred Method of Contact: ☐ Phone ☐ Email ☐ Mail ☐ Through ombudsman only

2.8. May the agency disclose your identity to the facility? ☐ Yes ☐ No (anonymous to extent permitted by law)

3. RESIDENT INFORMATION

3.1. Resident Legal Name: [________________________________]

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

3.3. Room / Unit Number: [________________________________]

3.4. Date of Admission: [__/__/____]

3.5. Payor Source: ☐ Medicare A ☐ Medicaid ☐ Medicare Advantage ☐ Long-term care insurance ☐ Private pay ☐ VA ☐ Other: [__________]

3.6. Diagnoses Relevant to Complaint: [________________________________]

3.7. Cognitive Status: ☐ Capable of directing care ☐ Diminished capacity ☐ Adjudicated incompetent ☐ Unknown

3.8. Surrogate Decisionmaker: ☐ Health-care POA ☐ Guardian ☐ Conservator ☐ Spouse ☐ Adult child — Name & contact: [________________________________]

3.9. Resident Consent to File this Complaint (required for Ombudsman action under 42 U.S.C. § 3058g and 45 C.F.R. § 1324.11): ☐ Resident consents ☐ Resident lacks capacity; surrogate consents ☐ Resident objects

4. FACILITY INFORMATION

4.1. Facility Name: [________________________________]

4.2. Address: [________________________________]

4.3. Phone: [________________________________]

4.4. Administrator: [________________________________]

4.5. Director of Nursing: [________________________________]

4.6. Facility Type:

☐ Skilled Nursing Facility (SNF)
☐ Nursing Facility (NF)
☐ Assisted Living / Personal Care Category A, B, or C
☐ Adult Foster Home
☐ Long-Term Care Hospital
☐ Memory Care Unit
☐ Other: [__________]

4.7. CMS Certification Number (CCN), if known: [________________________________]

4.8. Montana DPHHS License Number, if known: [________________________________]

4.9. Corporate Owner / Operator: [________________________________]

5. STATEMENT OF RIGHTS VIOLATED

The complainant alleges that the facility violated one or more of the following rights guaranteed to the resident under federal and Montana law (check all that apply):

Federal Nursing Home Reform Act (42 U.S.C. § 1396r; 42 C.F.R. Part 483, Subpart B):

☐ Right to be free from physical or chemical restraints not required to treat medical symptoms (§ 483.10(e); § 483.12)
☐ Right to be free from abuse, neglect, misappropriation of property, and exploitation (§ 483.12)
☐ Right to dignity, respect, and self-determination (§ 483.10)
☐ Right to participate in care planning and informed consent (§ 483.10(c); § 483.21)
☐ Right to refuse treatment and to formulate advance directives (§ 483.10(c)(6))
☐ Right to privacy and confidentiality of records (§ 483.10(h))
☐ Right to voice grievances without reprisal (§ 483.10(j))
☐ Right to access ombudsman, advocate, family, surveyors (§ 483.10(f), (g))
☐ Right to notice of services and charges (§ 483.10(g)(17), (18))
☐ Transfer/discharge protections — only for permitted reasons, with 30-day notice and right to appeal (§ 483.15)
☐ Right to bedhold and readmission after hospitalization (§ 483.15(d), (e))
☐ Right to manage personal funds (§ 483.10(f)(10))
☐ Right to a safe, clean, comfortable environment (§ 483.10(i))
☐ Right to sufficient nursing staff (§ 483.35) and quality of care (§ 483.25)

Montana Long-Term Care Residents' Bill of Rights (Mont. Code Ann. § 50-5-1104):

☐ At least 30 days' advance notice of changes in cost or availability of services (§ 50-5-1104(2)(a))
☐ Examination and explanation of monthly bill on request (§ 50-5-1104(2)(b))
☐ Right to organize and participate in resident councils (§ 50-5-1104(2)(c))
☐ Right to present grievances and have written grievance procedures (§ 50-5-1104(2)(d))
☐ Right to seek assistance from outside agencies free of restraint, interference, or reprisal (§ 50-5-1104(2)(e))
☐ Decisionmaking rights in all aspects of health care, including placement and treatment (§ 50-5-1104(2)(f))
☐ Prompt notice to representative of significant accident, unexplained absence, or significant change in condition (§ 50-5-1104(2)(g))
☐ Freedom from verbal, mental, and physical abuse, neglect, and financial exploitation (§ 50-5-1104(2)(h))
☐ Privacy in the resident's room with staff announcement upon entry (§ 50-5-1104(2)(i))
☐ At least 21 days' written notice of involuntary transfer or discharge except in emergency or documented medical reason (§ 50-5-1104(2)(j))
☐ Reasonable-fit clothing where facility supplies clothing (§ 50-5-1104(2)(k))
☐ Safeguarding of small valuables (§ 50-5-1104(2)(l))
☐ Prompt investigation and notification of theft or loss (§ 50-5-1104(2)(m))

6. FACTUAL ALLEGATIONS

6.1. On [__/__/____] at approximately [__:__ AM/PM], the following occurred: [____________________________________________________________]

6.2. Witnesses present:

6.3. Pattern / Frequency. The conduct ☐ is a single isolated incident ☐ is part of an ongoing pattern beginning approximately [__/__/____] ☐ was previously reported to facility on [__/__/____] with response [__________].

6.4. Resulting Harm. As a direct result, the resident has suffered: ☐ Physical injury (describe) ☐ Emotional distress ☐ Pressure ulcer / skin breakdown ☐ Falls ☐ Medication error ☐ Weight loss / dehydration ☐ Financial loss of $[__________] ☐ Loss of personal property ☐ Other: [__________]

6.5. Documentation Attached:

☐ Photographs of injury / condition
☐ Medical / clinical records
☐ Care plan / MDS assessment
☐ Facility incident report
☐ Bank / financial records
☐ Correspondence with administrator
☐ Discharge / transfer notice
☐ Grievance log entry
☐ Witness statements
☐ Other: [__________]

7. SPECIFIC CONDUCT AND STATUTORY VIOLATIONS

7.1. Quality of Care (42 C.F.R. § 483.25). Specific care failures: [________________________________]

7.2. Abuse / Neglect / Exploitation (42 C.F.R. § 483.12; Mont. Code Ann. § 50-5-1104(2)(h); § 52-3-811 reporting trigger). Description: [________________________________]

7.3. Staffing (42 C.F.R. § 483.35). Number of staff observed on shift; ratio concerns: [________________________________]

7.4. Improper Use of Restraint (42 C.F.R. § 483.10(e); § 483.12(a)(2)). Type, duration, indication, consent: [________________________________]

7.5. Improper Transfer / Discharge (42 C.F.R. § 483.15(c); Mont. Code Ann. § 50-5-1104(2)(j)).

• Date of notice: [__/__/____]
• Notice period given: [____] days (Montana minimum: 21 days)
• Reason cited by facility: [__________]
• Appeal filed: ☐ Yes ☐ No — Date: [__/__/____]
• Bedhold / readmission rights asserted: ☐ Yes ☐ No

7.6. Resident Funds (42 C.F.R. § 483.10(f)(10)). Concerns regarding the resident's trust fund / personal needs account: [________________________________]

7.7. Notice and Billing (Mont. Code Ann. § 50-5-1104(2)(a), (b)). Description: [________________________________]

7.8. Privacy / Dignity (42 C.F.R. § 483.10(h); Mont. Code Ann. § 50-5-1104(2)(i)). Description: [________________________________]

7.9. Retaliation (42 C.F.R. § 483.10(j); Mont. Code Ann. § 50-5-1104(2)(e)). Description: [________________________________]

8. RESIDENT CONSENT AND CONFIDENTIALITY

8.1. Ombudsman Authority. Pursuant to 42 U.S.C. § 3058g and 45 C.F.R. § 1324.11(e)(2), the Long-Term Care Ombudsman acts on behalf of the resident with the resident's consent (or the consent of a duly authorized surrogate where the resident lacks capacity).

8.2. Resident Consent (sign or initial):

☐ I, the resident, consent to the filing of this complaint and authorize the Ombudsman / DPHHS to investigate, including access to my clinical and financial records as necessary.

[________________________________]

Resident Signature — Date: [__/__/____]

8.3. Surrogate Consent (where resident lacks capacity):

☐ I am the resident's ☐ guardian ☐ POA ☐ spouse ☐ adult child and consent on the resident's behalf based on documentation attached.

[________________________________]

Surrogate Signature — Date: [__/__/____]

8.4. Disclosure Limits. Information provided to the Ombudsman is confidential under 42 U.S.C. § 3058g(d) and 45 C.F.R. § 1324.11(e)(3). Information provided to DPHHS QAD is treated under Mont. Code Ann. § 50-5-106 and applicable rules.

9. REMEDIES AND RELIEF SOUGHT

The complainant requests one or more of the following (check all that apply):

☐ Immediate on-site investigation by DPHHS QAD survey team
☐ Ombudsman intervention to negotiate informal resolution with the facility
☐ Issuance of a Statement of Deficiencies (CMS Form 2567) and required Plan of Correction
☐ Civil money penalty pursuant to 42 C.F.R. Part 488, Subpart F
☐ Denial of payment for new admissions
☐ Directed in-service training of facility staff
☐ Termination of provider agreement (in cases of immediate jeopardy)
☐ Rescission of involuntary transfer or discharge and reinstatement of resident to prior room
☐ Restoration of misappropriated property or funds
☐ Care-plan revision and reassessment by a qualified clinician
☐ Referral to Adult Protective Services (Mont. Code Ann. § 52-3-811)
☐ Referral to law enforcement / county attorney
☐ Referral to Montana Attorney General Medicaid Fraud Control Unit
☐ Other: [________________________________]

10. ANTI-RETALIATION NOTICE

10.1. Federal regulation (42 C.F.R. § 483.10(j)(4)) and Montana statute (Mont. Code Ann. § 50-5-1104(2)(e)) prohibit the facility from interfering with, threatening, or retaliating against any resident, family member, or staff member for filing or participating in this complaint.

10.2. The facility shall not discharge, transfer, demote, suspend, terminate, harass, or in any other manner discriminate against any person because of the filing of this complaint or cooperation with the investigation.

10.3. Acts of suspected retaliation should be reported immediately to the Ombudsman (1-800-332-2272), DPHHS QAD, and, where appropriate, Adult Protective Services (1-844-277-9300) and law enforcement.

11. VERIFICATION AND SIGNATURE

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

Date: [__/__/____]

[________________________________]

Complainant Signature

Print Name: [________________________________]

Capacity: ☐ Resident ☐ Authorized Representative ☐ Other: [__________]

Notarization (optional but recommended):

State of Montana, County of [________________________________]

Subscribed and sworn before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public

(My commission expires: [_______________])

12. SERVICE / FILING DISTRIBUTION

13. MONTANA PRACTICE NOTES

• Two parallel tracks. The Long-Term Care Ombudsman is a resident-directed advocate and acts only with consent; DPHHS Quality Assurance Division is the regulator with survey, citation, and enforcement power. Filing with both is permissible and often advisable.
• Federal floor. The federal Nursing Home Reform Act (OBRA '87, 42 U.S.C. §§ 1395i-3, 1396r) and 42 C.F.R. Part 483 set a national minimum for resident rights; Montana adopts these by reference and adds enhancements at Mont. Code Ann. § 50-5-1104.
• Notice of transfer/discharge. Federal rule requires 30-day written notice to resident and representative (42 C.F.R. § 483.15(c)(4)) and an opportunity to appeal to the State. Montana statute requires at least 21 days' written notice (§ 50-5-1104(2)(j)) absent emergency or documented medical necessity. The greater protection controls.
• Bedhold rights. Medicaid residents are entitled to written notice of bedhold policy and readmission rights upon transfer to a hospital or therapeutic leave (42 C.F.R. § 483.15(d)–(e)).
• Resident funds. Where the facility holds resident funds in excess of $50, federal law requires a separate, interest-bearing account and quarterly statements (42 C.F.R. § 483.10(f)(10)).
• Staffing. Facilities must have sufficient nursing staff "to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident" (42 C.F.R. § 483.35). CMS adopted minimum staffing standards in 2024; status is subject to ongoing rulemaking and litigation — verify current standard.
• Survey data. Past surveys, deficiencies, and enforcement history are available on Medicare's Care Compare (https://www.medicare.gov/care-compare/).
• Civil money penalties and remedies. CMS may impose CMPs ranging up to thousands of dollars per day or per instance under 42 C.F.R. § 488.408, and may deny payment for new admissions or terminate the provider agreement for immediate jeopardy.
• Private right of action. Federal courts are split on whether NHRA confers a private right of action under 42 U.S.C. § 1983; Montana common law claims (negligence, negligent hiring/supervision, breach of contract, statutory violations under § 50-5-1104) are independently available.
• Statute of limitations. Personal injury claims arising from facility neglect are governed by Mont. Code Ann. § 27-2-204 (3-year general tort) and, where medical malpractice is involved, § 27-2-205 (3-year, with discovery rule and 5-year statute of repose). Pre-litigation review by the Montana Medical Legal Panel is required for malpractice (§ 27-6-301).
• Arbitration agreements. Verify whether the resident or representative signed a pre-dispute arbitration agreement and whether it complies with 42 C.F.R. § 483.70(n) (post-2019 federal rule). Many such agreements are voidable for lack of capacity or improper execution.
• Tribal facilities. For facilities on tribal land or operated by IHS or a tribe under self-governance, jurisdictional and survey arrangements differ; coordinate with the tribal health authority and CMS Region 8.

14. SOURCES AND REFERENCES

• Montana Long-Term Care Ombudsman Program: https://dphhs.mt.gov/sltc/aging/longtermcareombudsman/
• Long-Term Care Ombudsman Directory: https://dphhs.mt.gov/SLTC/aging/longtermcareombudsman/index
• Montana Long-Term Care Ombudsman Brochure: https://dphhs.mt.gov/assets/sltc/Ombudsman/MTLongTermCareOmbudsmanProgramBrochure.pdf
• Montana Long-Term Care Ombudsman Policies & Procedures: https://dphhs.mt.gov/assets/sltc/Ombudsman/MTOmbudsmanPolicyProcedures.pdf
• DPHHS Quality Assurance Division — Complaints: https://dphhs.mt.gov/oig/QADComplaint
• Mont. Code Ann. § 50-5-1101 (Short title): https://archive.legmt.gov/bills/mca/title_0500/chapter_0050/part_0110/section_0010/0500-0050-0110-0010.html
• Mont. Code Ann. § 50-5-1104 (Rights of long-term care residents): https://mca.legmt.gov/bills/mca/title_0500/chapter_0050/part_0110/section_0040/0500-0050-0110-0040.html
• Title 50, Chapter 5, Part 11 (Long-Term Health Care Facilities): https://archive.legmt.gov/bills/mca/title_0500/chapter_0050/part_0110/sections_index.html
• Admin. R. Mont. 37.106.2828 (Resident Rights): https://rules.mt.gov/gateway/ruleno.asp?RN=37.106.2828
• 42 U.S.C. § 1395i-3 (Medicare SNF requirements)
• 42 U.S.C. § 1396r (Medicaid NF requirements — NHRA)
• 42 C.F.R. Part 483 (Requirements for Long-Term Care Facilities)
• 42 U.S.C. § 3058g (State Long-Term Care Ombudsman Program — OAA)
• 45 C.F.R. § 1324 (Older Americans Act regulations — Ombudsman)
• CMS Care Compare: https://www.medicare.gov/care-compare/
• Montana Adult Protective Services: https://dphhs.mt.gov/SLTC/APS/ — Hotline 1-844-277-9300

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Montana-licensed attorney should review and customize this complaint where damages, eviction, or guardianship issues arise. If a resident is in immediate danger, call 911.