Nebraska Nursing Home Resident Complaint (LTC Ombudsman / DHHS Licensure)

NEBRASKA NURSING HOME RESIDENT COMPLAINT

TABLE OF CONTENTS

1. Routing Header — Where This Complaint Is Filed
2. Complainant Information
3. Resident Information
4. Facility Information
5. Summary of Complaint
6. Specific Resident Rights Implicated
7. Detailed Factual Allegations
8. Evidence and Witnesses
9. Internal Grievance History
10. Relief / Action Requested
11. Confidentiality and Authorization
12. Parallel Notifications
13. Signature
14. Nebraska Practice Notes
15. Sources and References

1. ROUTING HEADER — WHERE THIS COMPLAINT IS FILED

This complaint is filed concurrently with (check all that apply):

• ☐ Nebraska State Long-Term Care Ombudsman — Nebraska DHHS State Unit on Aging, P.O. Box 95044, Lincoln, NE 68509-5044 / Tel. 402-471-2307 / 1-800-942-7830 / dhhs.ne.gov/Pages/Aging-Ombudsman.aspx
• ☐ Local LTC Ombudsman Program at Area Agency on Aging serving [COUNTY]: [________________________________]
• ☐ DHHS Public Health Division — Office of Long-Term Care Facilities, Licensure Unit, P.O. Box 95026, Lincoln, NE 68509-5026 / Tel. 402-471-0316 / Complaint line [verify current number]
• ☐ Nebraska APS Hotline — 1-800-652-1999 (where abuse, neglect, or exploitation is alleged)
• ☐ CMS / State Survey Agency (for Medicare/Medicaid-certified facility deficiencies)
• ☐ Nebraska Attorney General — Medicaid Fraud and Patient Abuse Unit (Medicaid fraud, criminal patient abuse)
• ☐ Local law enforcement — Agency: [__________] Report #: [__________]

Date submitted: [__/__/____]

2. COMPLAINANT INFORMATION

3. RESIDENT INFORMATION

4. FACILITY INFORMATION

5. SUMMARY OF COMPLAINT

In one or two paragraphs, state the essence of the complaint, including the date(s), nature of harm, and what action is requested:

[________________________________________________________________________________________________________________________________________________________________________]

[________________________________________________________________________________________________________________________________________________________________________]

6. SPECIFIC RESIDENT RIGHTS IMPLICATED

(Check all that apply. These are drawn from federal NHRA / 42 C.F.R. § 483.10 and Nebraska's Nursing Home Act / Title 175 NAC, Ch. 12.)

Dignity, autonomy, and self-determination

• ☐ Right to be treated with consideration, respect, and full recognition of dignity and individuality (42 C.F.R. § 483.10(a))
• ☐ Right to privacy in accommodations, medical treatment, communications, and personal care
• ☐ Right to self-determination, including choice of physician, schedule, activities, and resident-and-family councils

Freedom from abuse, neglect, and unnecessary restraint

• ☐ Right to be free from physical, sexual, mental, verbal, and financial abuse
• ☐ Right to be free from neglect and exploitation
• ☐ Right to be free from physical or chemical restraints imposed for purposes of discipline or convenience

Care planning and clinical care

• ☐ Right to be informed of total health status and to participate in care planning
• ☐ Right to refuse treatment and to formulate advance directives
• ☐ Right to receive services with reasonable accommodation of needs and preferences (42 C.F.R. § 483.10(e))
• ☐ Right to adequate and appropriate medical, nursing, dietary, and rehabilitative services

Transfer and discharge

• ☐ Right to advance written notice of involuntary transfer or discharge and right to appeal (42 C.F.R. § 483.15; Title 175 NAC ch. 12)
• ☐ Right to bed-hold and readmission protections

Grievance, communication, and access

• ☐ Right to voice grievances without discrimination or reprisal and to prompt resolution
• ☐ Right of access to ombudsman, family, attorney, clergy, surveyors, and physician
• ☐ Right to private communication, including telephone, mail, and visits
• ☐ Right to organize and participate in resident and family councils

Property, finances, and contracts

• ☐ Right to manage personal financial affairs (or have an accounting where managed by facility)
• ☐ Right to be informed in writing of services and charges before admission and during stay
• ☐ Right to be free from improper admission contract terms (e.g., third-party guarantor, mandatory pre-dispute arbitration as a condition of admission — see 42 C.F.R. § 483.70(n))

Other: [________________________________]

7. DETAILED FACTUAL ALLEGATIONS

7.1. Chronological narrative. State each incident with date, time, location within the facility, persons involved, what was observed or experienced, and resulting harm. Use direct observation and quoted statements where possible; flag hearsay as such.

7.2. Pattern and recurrence. Describe whether the conduct is a single event or a recurring pattern, citing prior dates and any staff or shift correlations.

[________________________________________________________________________________________________________]

7.3. Clinical impact on resident. Describe weight changes, pressure ulcers, falls, infections, hospitalizations, medication errors, behavioral changes, financial losses, or other measurable harm.

[________________________________________________________________________________________________________]

8. EVIDENCE AND WITNESSES

8.1. Documents available (attach copies, not originals):

• ☐ Photographs (date-stamped)
• ☐ Care plan and MDS excerpts
• ☐ Physician orders / medication administration records (MAR)
• ☐ Nursing notes / progress notes
• ☐ Hospital discharge summaries / ER records
• ☐ Incident reports / facility logs
• ☐ Communication with administrator (letters, emails, texts)
• ☐ Admission agreement / arbitration addendum
• ☐ Trust-fund / personal-needs-account statements
• ☐ Receipts for missing items
• ☐ Resident's diary / family contemporaneous notes
• ☐ Surveillance video (if obtained)
• ☐ Other: [__________]

8.2. Witnesses:

9. INTERNAL GRIEVANCE HISTORY

9.1. Did complainant or resident raise the issue with facility staff before this filing?

• ☐ Yes — date(s): [__/__/____], person(s): [__________], response: [__________________]
• ☐ No — reason: [__________________]

9.2. Facility grievance officer / resident-rights coordinator. Name: [__________]. Date contacted: [__/__/____]. Response: [__________________].

9.3. Resident or Family Council. ☐ Issue raised — date: [__/__/____] ☐ No council exists ☐ Council nonresponsive

9.4. Retaliation concerns. ☐ Resident has experienced or reasonably fears retaliation. Describe: [__________________].

10. RELIEF / ACTION REQUESTED

(Check all that apply.)

• ☐ Investigation by the Long-Term Care Ombudsman with resident-directed advocacy
• ☐ On-site complaint survey by DHHS Licensure Unit
• ☐ Issuance of statements of deficiency and required plan of correction
• ☐ Civil monetary penalties or other enforcement remedies under 42 C.F.R. Part 488
• ☐ Referral to Adult Protective Services
• ☐ Referral to law enforcement and/or the Attorney General's Medicaid Fraud and Patient Abuse Unit
• ☐ Immediate cessation of involuntary transfer/discharge and reinstatement
• ☐ Restoration of personal funds and accounting of trust account
• ☐ Care-plan revision, additional staffing, retraining, or specific clinical intervention
• ☐ Facility-level corrective action and confirmation of follow-up
• ☐ Other: [__________________]

11. CONFIDENTIALITY AND AUTHORIZATION

11.1. Confidentiality. I request that my identity, and the identity of the resident where applicable, be treated as confidential to the maximum extent permitted by the Older Americans Act, 42 U.S.C. § 3058g(d) (Ombudsman confidentiality), Neb. Rev. Stat. §§ 71-6008 to 71-6043 (Nursing Home Act), Title 175 NAC, and Neb. Rev. Stat. §§ 28-348 to 28-387 (APS Act), and that disclosure occur only with my written consent or as required by law.

11.2. HIPAA authorization. ☐ Attached. The resident, or the resident's authorized legal representative, authorizes the receiving agency to obtain and review medical records relevant to this complaint pursuant to 45 C.F.R. § 164.508 and § 164.512.

11.3. Non-retaliation. I understand that Nebraska law and federal regulation prohibit retaliation against a resident or person who files a complaint or cooperates in an investigation. Any retaliation should be reported immediately to the Ombudsman and DHHS.

12. PARALLEL NOTIFICATIONS

(Note here any parallel filings or referrals.)

13. SIGNATURE

I declare under penalty of perjury under the laws of the State of Nebraska that the information set forth in this complaint is true and correct to the best of my knowledge and belief, and that I am submitting this complaint in good faith for the protection of the resident named above.

[________________________________]

[COMPLAINANT NAME]

Title / capacity: [____________]

Date: [__/__/____]

(Optional) Acknowledged before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public — State of Nebraska

(My Commission Expires: [__/__/____])

14. NEBRASKA PRACTICE NOTES

• Two complementary tracks. The Long-Term Care Ombudsman provides resident-directed, confidential advocacy and informal resolution under the Older Americans Act and Nebraska's State Unit on Aging. DHHS Licensure conducts regulatory enforcement under Title 175 NAC and federal certification rules, and can issue deficiencies, civil monetary penalties, denial of payment for new admissions, and termination from Medicare/Medicaid.
• Federal floor. Even where Nebraska statutes are silent, 42 C.F.R. Part 483 establishes a baseline of resident rights for Medicare/Medicaid-certified facilities. Federal "F-tags" are useful in framing licensure complaints (e.g., F600 abuse, F684 quality of care, F689 falls/accidents, F622 transfer/discharge, F580 notification of changes, F636/F656 care planning, F689 supervision, F761 medication errors).
• State statutory framework. The Nebraska Nursing Home Act, Neb. Rev. Stat. §§ 71-6008 to 71-6043, plus the Health Care Facility Licensure Act, §§ 71-401 to 71-475, plus Title 175 NAC Chapter 12, establish licensure standards, resident rights, transfer/discharge protections, and enforcement.
• Confidentiality of Ombudsman files. 42 U.S.C. § 3058g(d) requires Ombudsman programs to maintain the confidentiality of files and records. Disclosure generally requires the consent of the resident (or the legal representative) or court order.
• Survey and investigation timelines. DHHS triages complaints by severity. Immediate jeopardy complaints are typically investigated within two business days; high-priority complaints within ten business days; others within statutory windows. Resolution timing for Ombudsman matters varies with complexity and resident wishes.
• Arbitration agreements. Federal regulation (42 C.F.R. § 483.70(n)) prohibits making admission contingent on signing a pre-dispute binding arbitration agreement and imposes notice and rescission requirements. Flag any apparent violation in the complaint.
• Retaliation. Nebraska law and federal regulation prohibit retaliation. If retaliation occurs (e.g., transfer threats, room reassignment, restricted visits), file an immediate supplemental complaint and consider injunctive relief.
• Civil remedies. A regulatory complaint does not preclude civil claims for negligence, statutory residents' rights violations, breach of admission contract, or wrongful death. Preserve evidence and consult counsel about Nebraska's general personal-injury statute of limitations (Neb. Rev. Stat. § 25-208) and any shorter periods applicable to specific claims.
• Criminal exposure. Knowing abuse, neglect, or exploitation of a vulnerable adult is a crime under Neb. Rev. Stat. §§ 28-386 and 28-387. Coordinate with law enforcement and the Attorney General's Medicaid Fraud and Patient Abuse Unit where appropriate.
• Estate/financial concerns. Where the complaint involves trust-fund mismanagement or financial exploitation, request a written accounting of the resident's personal-needs account and consider notifying the resident's bank and any fiduciaries (POA, guardian).

15. SOURCES AND REFERENCES

• Nebraska Nursing Home Act, Neb. Rev. Stat. §§ 71-6008 to 71-6043 — https://nebraskalegislature.gov/laws/statutes.php?statute=71-6008
• Health Care Facility Licensure Act, Neb. Rev. Stat. §§ 71-401 to 71-475
• Title 175 Neb. Admin. Code, Ch. 12 (Nursing Facilities) — https://rules.nebraska.gov/
• 42 U.S.C. §§ 1395i-3, 1396r (Federal Nursing Home Reform Act / OBRA '87)
• 42 C.F.R. Part 483, Subpart B (resident rights and quality of care) — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• Older Americans Act, 42 U.S.C. § 3058g (State LTC Ombudsman Program)
• Adult Protective Services Act, Neb. Rev. Stat. §§ 28-348 to 28-387
• DHHS Long-Term Care Ombudsman — https://dhhs.ne.gov/Pages/Aging-Ombudsman.aspx
• DHHS Office of Long-Term Care Facilities (Licensure) — https://dhhs.ne.gov/Pages/Public-Health-Licensure.aspx
• Nebraska APS Hotline — 1-800-652-1999
• Nebraska Attorney General — Medicaid Fraud and Patient Abuse Unit — https://ago.nebraska.gov/
• LTCO Residents' Rights Brochure — https://dhhs.ne.gov/Medicaid%20SUA/LTCO%20Residents%20Rights%20Brochure.pdf
• LTCO Residents' Rights Poster — https://dhhs.ne.gov/Documents/LTCO%20Residents%20Rights%20Poster.pdf
• CMS Nursing Home Compare — https://www.medicare.gov/care-compare/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Filing a complaint does not waive any private right of action. An attorney licensed in Nebraska should review and customize this document before submission, particularly where the conduct may give rise to civil or criminal liability or where retaliation is a concern.