Nevada Nursing Home Resident Complaint — Long-Term Care Ombudsman and Bureau of Health Care Quality and Compliance

NEVADA NURSING HOME RESIDENT COMPLAINT — LONG-TERM CARE OMBUDSMAN AND BUREAU OF HEALTH CARE QUALITY AND COMPLIANCE

TABLE OF CONTENTS

1. Cover Sheet and Routing
2. Resident Identification
3. Facility Identification
4. Complainant and Authority
5. Resident Consent and Confidentiality
6. Statement of Concerns
7. Specific Resident Rights Implicated
8. Chronology of Events
9. Internal Grievance / Notice to Facility
10. Relief Requested
11. Supporting Documents
12. Verification
13. Service / Distribution List
14. Nevada Practice Notes
15. Sources and References

1. COVER SHEET AND ROUTING

2. RESIDENT IDENTIFICATION

3. FACILITY IDENTIFICATION

4. COMPLAINANT AND AUTHORITY

5. RESIDENT CONSENT AND CONFIDENTIALITY

I, [RESIDENT NAME] (or representative), authorize the Nevada Long-Term Care Ombudsman and the Bureau of Health Care Quality and Compliance to:

• ☐ Investigate the concerns described in this complaint;
• ☐ Access my medical and resident records to the extent necessary;
• ☐ Communicate with my facility, physicians, family members, and surrogate decisionmaker(s) listed above;
• ☐ Disclose my identity to the facility (otherwise, identity will be kept confidential to the extent permitted by 45 C.F.R. § 1324.11(e)(3) and NRS 427A.1255).

Signed: [________________________________] Date: [__/__/____]

[RESIDENT or REPRESENTATIVE NAME, TITLE, AUTHORITY]

6. STATEMENT OF CONCERNS

Provide a concise (one-paragraph) executive summary, then expand by category as relevant.

6.1. Executive summary:

[________________________________]

6.2. Care and clinical concerns (e.g., pressure injuries, falls without documented assessment, untreated pain, dehydration, weight loss, medication errors, unaddressed infection, restraints):

[________________________________]

6.3. Staffing concerns (e.g., insufficient nurse-to-resident ratio, untrained aides, failure to answer call lights, mandatory overtime impacting care):

[________________________________]

6.4. Dignity, autonomy, and quality of life (e.g., disrespectful treatment, denial of choices, denial of privacy, denial of access to personal items, restriction of visitation, inability to participate in care plan):

[________________________________]

6.5. Discharge or transfer concerns (e.g., involuntary transfer without 30-day written notice, inadequate discharge planning, dumping to emergency room, retaliatory discharge for grievance):

[________________________________]

6.6. Financial concerns (e.g., misuse of personal funds account, improper charges, denial of refund, exploitation by staff, unauthorized billing):

[________________________________]

6.7. Safety and abuse concerns (e.g., unwitnessed bruises, allegations of physical/sexual abuse, theft by staff, unsafe physical environment, insufficient infection control):

[________________________________]

7. SPECIFIC RESIDENT RIGHTS IMPLICATED

The following rights, conferred by federal and Nevada law, appear to have been violated (check all that apply):

Federal (42 C.F.R. § 483.10 – § 483.25):

• ☐ Right to a dignified existence and self-determination (§ 483.10(a))
• ☐ Right to be informed and to participate in planning care (§ 483.10(c))
• ☐ Right to choose attending physician (§ 483.10(d))
• ☐ Right to be free from physical or chemical restraints not required to treat medical symptoms (§ 483.12(a))
• ☐ Right to be free from abuse, neglect, misappropriation of property, and exploitation (§ 483.12)
• ☐ Right to voice grievances without discrimination or reprisal (§ 483.10(j))
• ☐ Right to manage personal financial affairs (§ 483.10(f)(10))
• ☐ Right to privacy and confidentiality (§ 483.10(h))
• ☐ Right to receive visitors of one's choosing (§ 483.10(f)(4))
• ☐ Right to advance written notice (generally 30 days) of transfer or discharge and the bases permitted by § 483.15
• ☐ Right to have advance directives respected (§ 483.10(c)(6))
• ☐ Right to receive necessary services to attain or maintain highest practicable physical, mental, and psychosocial well-being (§ 483.25)
• ☐ Right to participate in resident or family councils (§ 483.10(f)(5)–(6))

Nevada (NRS Chapter 449A and the Patient's Bill of Rights):

• ☐ Right to receive necessary services or be transferred to a facility that can provide them (formerly NRS 449.700, recodified within NRS 449A)
• ☐ Right to information regarding the facility, treatment, and billing
• ☐ Right to refuse treatment and experimentation
• ☐ Right to privacy and confidentiality of patient information
• ☐ Right to be informed of rights upon admission and to receive a written copy
• ☐ Right to access the Long-Term Care Ombudsman and to communicate with surveyors
• ☐ Right to be free from retaliation for filing a grievance

8. CHRONOLOGY OF EVENTS

9. INTERNAL GRIEVANCE / NOTICE TO FACILITY

42 C.F.R. § 483.10(j) requires every facility to maintain a grievance process and a designated grievance official. Document attempts to resolve internally before escalating.

10. RELIEF REQUESTED

The complainant requests that the Ombudsman, BHCQC, and/or CMS take the following actions (check all that apply):

• ☐ Immediate on-site investigation by the Ombudsman or BHCQC surveyor.
• ☐ Issuance of a Statement of Deficiencies (CMS-2567) identifying the federal and state regulatory violations.
• ☐ Imposition of remedies under 42 C.F.R. § 488.406 (directed plan of correction, civil money penalty, denial of payment for new admissions, state-monitor placement, temporary management, and/or termination of provider agreement, as warranted).
• ☐ Issuance of state licensure remedies under NRS Chapter 449 (including civil penalties, suspension, or revocation).
• ☐ Restoration of the resident to the prior room, status, services, or property where unlawful change occurred.
• ☐ Rescission of an involuntary transfer or discharge that did not comply with 42 C.F.R. § 483.15.
• ☐ Care-plan revision with measurable goals and clinical follow-up.
• ☐ Refund / accounting of disputed financial charges and any misappropriated personal-needs funds.
• ☐ Referral to law enforcement and the Attorney General's Medicaid Fraud Control Unit for criminal investigation.
• ☐ Protection of the resident, complainant, and any staff witnesses against retaliation, including documentation by surveyors.
• ☐ Other: [________________________________]

11. SUPPORTING DOCUMENTS

• ☐ Admission agreement and resident-rights acknowledgment
• ☐ Most recent care plan and MDS 3.0 assessment
• ☐ Physician orders relevant to allegations
• ☐ Medication Administration Records (MARs)
• ☐ Treatment Administration Records (TARs)
• ☐ Nursing notes / progress notes
• ☐ Incident reports / falls reports
• ☐ Photographs of injuries or environmental conditions (with date stamps)
• ☐ Personal-needs account ledger
• ☐ Billing statements / Medicare/Medicaid EOMBs
• ☐ Written grievance(s) submitted to facility and any responses
• ☐ Power of attorney / guardianship order
• ☐ Health-care advance directive / POLST
• ☐ Communications with staff (emails, text messages)
• ☐ Witness statements
• ☐ Other: [________________________________]

12. VERIFICATION

I declare under penalty of perjury under the laws of the State of Nevada that the foregoing complaint, including all attachments, is true and correct to the best of my knowledge, information, and belief, and that I am submitting this complaint in good faith.

Signed: [________________________________] Date: [__/__/____]

[COMPLAINANT NAME / TITLE]

Subscribed and sworn to before me (if required) this [____] day of [_______________], 20[____].

[________________________________]

Notary Public — State of Nevada

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

13. SERVICE / DISTRIBUTION LIST

Copies of this complaint have been transmitted to:

14. NEVADA PRACTICE NOTES

• Two parallel tracks. The Long-Term Care Ombudsman is a resident-advocacy program; BHCQC is the regulatory arm enforcing licensure and federal certification standards. Filing with both maximizes the resident's options and creates an investigative record. CMS Region IX is the appropriate federal escalation for skilled nursing facilities certified under Medicare/Medicaid.
• Ombudsman confidentiality. Under the federal Older Americans Act and 45 C.F.R. § 1324.11(e)(3), the Ombudsman cannot release identifying information about a resident or complainant without consent. This protects the resident's autonomy but limits what the Ombudsman can do without a clear consent record (Section 5).
• Anti-retaliation. 42 U.S.C. § 1396r(c)(1)(A)(v) and 42 C.F.R. § 483.10(j)(4) prohibit retaliation for filing a grievance or for participating in an investigation. Document any retaliatory acts and report them immediately.
• Involuntary transfer/discharge. 42 C.F.R. § 483.15(c) limits the bases for transfer/discharge to six grounds (resident's welfare, improvement, safety of others, health of others, nonpayment, or facility closure) and requires 30 days' written notice with appeal rights to the State. Nevada appeals are conducted through the Department of Health and Human Services hearings unit.
• State and federal survey records. CMS Form 2567 deficiency reports are public via Care Compare (https://www.medicare.gov/care-compare). Nevada-specific survey results are available from BHCQC and may be useful evidence of pattern-and-practice.
• Criminal and civil parallel process. Allegations of abuse, neglect, exploitation, isolation, or abandonment trigger NRS 200.5093 reporting obligations. The Office of the Attorney General's Medicaid Fraud Control Unit (MFCU) prosecutes resident-abuse and Medicaid-fraud crimes in Medicaid-certified facilities. Civil claims (negligence, statutory damages, wrongful death) are not foreclosed by an Ombudsman or BHCQC investigation.
• Pre-dispute arbitration. CMS amended 42 C.F.R. § 483.70(n) to permit but heavily regulate pre-dispute arbitration agreements. Review the admission agreement carefully; an unsigned or improperly executed arbitration provision may not bind the resident, and post-dispute arbitration agreements remain at the resident's option.
• Personal-funds account. Facilities holding more than $50 of resident funds must maintain an interest-bearing account and provide quarterly accounting (42 C.F.R. § 483.10(f)(10)). Audit the ledger when financial concerns are raised.
• Visitation rights. Federal and state law recognize broad visitation rights, including during public-health emergencies subject to limited infection-control measures. Unjustified denial of visitation is a citable deficiency.

15. SOURCES AND REFERENCES

• Nevada Long-Term Care Ombudsman Program (ADSD) — https://adsd.nv.gov/Programs/Seniors/LTCOmbudsman/LTCOmbudsProg/
• LTC Ombudsman Helpline: 1-888-282-1155
• Nevada Bureau of Health Care Quality and Compliance — https://dpbh.nv.gov/Reg/HealthFacilities/dta/Hospitals/Health_Facilities_-_Hospitals/
• Nevada Department of Health and Human Services — https://dhhs.nv.gov
• CMS Care Compare (federal nursing-home survey results) — https://www.medicare.gov/care-compare
• CMS Region IX (San Francisco) — https://www.cms.gov/about-cms/where-we-are
• Nevada Office of the Attorney General — Medicaid Fraud Control Unit — https://ag.nv.gov/Hot_Topics/Issue/MFCU/
• Nevada Revised Statutes Chapter 449 (Medical Facilities) — https://www.leg.state.nv.us/division/legal/lawlibrary/nrs/NRS-449.html
• Nevada Revised Statutes Chapter 449A (Care and Rights of Patients) — https://www.leg.state.nv.us/NRS/NRS-449A.html
• Nevada Administrative Code Chapter 449 — https://www.leg.state.nv.us/NAC/NAC-449.html
• 42 C.F.R. Part 483 (federal LTC facility requirements) — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• National Long-Term Care Ombudsman Resource Center — https://ltcombudsman.org

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Verify all citations and contact information against current ADSD, BHCQC, and CMS publications before filing. A Nevada-licensed attorney should review any complaint with potential civil-litigation, retaliation, or guardianship implications.