South Dakota Nursing Home Resident Complaint — Department of Health, Long-Term Care Ombudsman, and Federal Enforcement

SOUTH DAKOTA NURSING HOME RESIDENT COMPLAINT

Federal Nursing Home Reform Act and South Dakota Resident Rights

TABLE OF CONTENTS

1. Header and Filing Channels
2. Complainant Information
3. Resident Information
4. Facility Information
5. Statement of Resident Rights Implicated
6. Specific Allegations and Chronology
7. Evidence and Witnesses
8. Internal Grievance Steps Taken
9. Relief Requested
10. Companion Filings and Cross-Referrals
11. Anti-Retaliation Demand
12. Verification and Signature
13. Sources and References

1. HEADER AND FILING CHANNELS

Date of complaint: [__/__/____]
Complaint reference number (assigned by DOH): [________________________________]

2. COMPLAINANT INFORMATION

Authority to act on resident's behalf:

• ☐ Resident is the complainant
• ☐ Power of attorney for health care or finances (attached, dated [__/__/____])
• ☐ Court-appointed guardian / conservator (order attached, dated [__/__/____])
• ☐ Family member with resident's verbal consent
• ☐ Long-term care ombudsman or licensed representative
• ☐ Other: [________________________________]

3. RESIDENT INFORMATION

4. FACILITY INFORMATION

5. STATEMENT OF RESIDENT RIGHTS IMPLICATED

The following resident rights, established by the federal Nursing Home Reform Act and South Dakota law, are alleged to have been violated. Check all that apply.

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

• ☐ § 483.10(a) — Right to dignity, respect, and self-determination
• ☐ § 483.10(c) — Right to participate in care planning, including refusal of treatment
• ☐ § 483.10(d) — Choice of attending physician
• ☐ § 483.10(e)(2) — Privacy and confidentiality of records and communications
• ☐ § 483.10(e)(3) — Visitation rights (also SDCL § 34-12-67)
• ☐ § 483.10(f)(1) — Right to make choices about activities, schedules, and care
• ☐ § 483.10(f)(4) — Right to organize and participate in resident/family councils
• ☐ § 483.10(g) — Information and communication (notice, access to records within 24 hours / copies within 2 working days)
• ☐ § 483.10(h) — Privacy and confidentiality
• ☐ § 483.10(i) — Safe environment
• ☐ § 483.10(j) — Grievances — right to voice grievances and receive timely response without retaliation

Federal — 42 C.F.R. § 483.12 (Freedom from Abuse, Neglect, and Exploitation):

• ☐ § 483.12(a)(1) — Free from abuse, neglect, misappropriation of property, and exploitation
• ☐ § 483.12(a)(2) — Free from physical or chemical restraints not required to treat medical symptoms
• ☐ § 483.12(b) — Facility's duty to develop and implement policies prohibiting abuse, neglect, exploitation; investigate and report

Federal — 42 C.F.R. § 483.15 (Admission, Transfer, Discharge):

• ☐ § 483.15(a) — Admission policy violations (Medicaid discrimination, illegal third-party guarantees)
• ☐ § 483.15(c) — Improper transfer or discharge (failure to meet one of six allowed bases)
• ☐ § 483.15(c)(3) — Inadequate notice (less than 30 days written notice with required content)
• ☐ § 483.15(c)(5) — Inadequate discharge planning / unsafe discharge
• ☐ § 483.15(d) — Notice of bed-hold policy on hospital transfer
• ☐ § 483.15(e) — Refusal to readmit after hospital transfer

Federal — 42 C.F.R. § 483.24 / § 483.25 (Quality of Life and Care):

• ☐ § 483.24 — Failure to provide care to attain or maintain highest practicable physical, mental, psychosocial well-being
• ☐ § 483.25(b) — Skin integrity / pressure injuries
• ☐ § 483.25(d) — Falls and accidents
• ☐ § 483.25(g) — Nutrition and hydration
• ☐ § 483.25(k) — Pain management
• ☐ § 483.25(l) — Dialysis / specialized care
• ☐ § 483.45 — Pharmacy services / unnecessary medications / antipsychotics without justification

Federal — Staffing and Administration:

• ☐ § 483.35 — Insufficient nursing staff (RN coverage, PPD requirements)
• ☐ § 483.70 — Administration / governance failures
• ☐ § 483.80 — Infection-control program (including outbreak response)

South Dakota — SDCL and ARSD:

• ☐ SDCL § 34-12-67 — Visitation rights
• ☐ SDCL ch. 34-12 / 34-12D — Licensing and resident protections
• ☐ ARSD Article 44:73 — Nursing facility operating standards
• ☐ ARSD Article 44:70 — Assisted living center standards (if applicable)
• ☐ SDCL ch. 22-46 — Abuse, neglect, or exploitation of elder/disabled adult (cross-reference APS report)

6. SPECIFIC ALLEGATIONS AND CHRONOLOGY

Provide a chronological narrative of the events, identifying date, time, location, persons involved, and the right(s) implicated for each incident.

6.1 Allegation Number One

Description (factual, no conclusions):

[____________________________________________________________]
[____________________________________________________________]
[____________________________________________________________]
[____________________________________________________________]

6.2 Allegation Number Two

Description:

[____________________________________________________________]
[____________________________________________________________]
[____________________________________________________________]

6.3 Allegation Number Three

Description:

[____________________________________________________________]
[____________________________________________________________]

6.4 Pattern of Conduct

☐ The above allegations represent isolated incidents.
☐ The above allegations represent a pattern. Pattern description:

[____________________________________________________________]
[____________________________________________________________]

7. EVIDENCE AND WITNESSES

Witnesses:

Records request status (42 C.F.R. § 483.10(g)(2)):

• ☐ Records request submitted [__/__/____]
• ☐ Inspection within 24 hours: ☐ Honored ☐ Refused
• ☐ Copies within 2 business days: ☐ Honored ☐ Refused
• ☐ Refusal documented; right to file separate complaint

8. INTERNAL GRIEVANCE STEPS TAKEN

42 C.F.R. § 483.10(j) requires facilities to maintain a grievance process. Document attempts before or alongside this complaint.

☐ Facility's written response to grievance is attached.
☐ Facility failed to provide a written grievance response within the time frame required by its policy.

9. RELIEF REQUESTED

The complainant respectfully requests that the receiving agencies take the following actions, as appropriate to their authority:

From the South Dakota Department of Health:

• ☐ Open a complaint investigation under 42 C.F.R. § 488 (CMS) and ARSD 44:73
• ☐ Conduct an unannounced on-site survey
• ☐ Issue Statement of Deficiencies (CMS-2567) with findings of substantial compliance failures
• ☐ Recommend federal enforcement remedies (civil money penalties, denial of payment, directed plan of correction, termination of provider agreement) per 42 C.F.R. § 488.404–.456
• ☐ Refer to South Dakota Board of Nursing Facility Administrators if administrator misconduct is implicated
• ☐ Referral to appropriate licensing boards for individual licensees (RN, LPN, CNA registry)

From the South Dakota Long-Term Care Ombudsman:

• ☐ Visit the resident and confirm safety
• ☐ Mediate between resident/family and facility leadership
• ☐ Advocate for restoration of denied rights
• ☐ Advocate for rescission of improper transfer/discharge
• ☐ Provide ongoing monitoring

From Adult Protective Services / law enforcement (if abuse, neglect, or exploitation per SDCL ch. 22-46):

• ☐ Open APS investigation
• ☐ Refer for criminal investigation under SDCL §§ 22-46-2, 22-46-3
• ☐ Coordinate with prosecutors

From the facility (informal resolution):

• ☐ Written apology and corrective action plan
• ☐ Reassignment of identified staff away from the resident
• ☐ Updated care plan addressing the issue
• ☐ Restoration of services or readmission
• ☐ Refund of charges or credit on account
• ☐ Replacement of misappropriated property

10. COMPANION FILINGS AND CROSS-REFERRALS

The complainant has also filed or intends to file the following:

• ☐ Adult Protective Services report — Date: [__/__/____] — Reference: [____________]
• ☐ Law-enforcement report — Agency: [____________] — Case #: [____________]
• ☐ Long-Term Care Ombudsman intake — Date: [__/__/____]
• ☐ CMS complaint (via DOH state-survey channel)
• ☐ South Dakota Board of Nursing complaint — Date: [__/__/____]
• ☐ South Dakota Board of Nursing Facility Administrators complaint — Date: [__/__/____]
• ☐ South Dakota Attorney General — Consumer Protection (605-773-4400 / 1-800-300-1986)
• ☐ Civil action — counsel retained: [____________]
• ☐ Medicare/Medicaid fraud referral (state Medicaid Fraud Control Unit) — if billing or services fraud is implicated
• ☐ Resident's care-plan team requested for emergency meeting

11. ANTI-RETALIATION DEMAND

42 C.F.R. § 483.10(b)(2), 42 U.S.C. § 1396r(c)(1)(A)(ii), and ARSD Article 44:73 prohibit retaliation against a resident for exercising rights, voicing grievances, or filing complaints. The facility, its corporate parent, and its agents are placed on notice that any of the following will be treated as retaliation and reported promptly:

• ☐ Involuntary transfer or discharge in proximity to this complaint
• ☐ Reduction in services, denial of care, or change in room assignment without medical justification
• ☐ Restriction of visitation, mail, telephone, or assembly rights
• ☐ Threats, intimidation, or harassment of resident or family
• ☐ Adverse changes in care plan or medication regimen lacking documented clinical basis
• ☐ Discharge to an unsafe setting (homelessness, hospital ED, family without notice)

The complainant requests that all retaliation, suspected retaliation, and changes in resident status during the pendency of this complaint be documented and disclosed to the Department of Health and the Ombudsman immediately.

12. VERIFICATION AND SIGNATURE

I declare under penalty of perjury under the laws of the State of South Dakota and the United States that the statements contained in this complaint are true and correct to the best of my knowledge, information, and belief; that I am authorized to make this complaint on behalf of the resident identified above; and that I file this complaint in good faith and not for any improper purpose.

Complainant signature: [________________________________]

Printed name: [________________________________]

Date: [__/__/____]

State of South Dakota, County of [____________]

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

[____________________________________]
Notary Public, State of South Dakota
My commission expires: [__/__/____]
(SEAL)

13. SOURCES AND REFERENCES

Federal authority:

• Nursing Home Reform Act — 42 U.S.C. § 1395i-3 (Medicare): https://www.ssa.gov/OP_Home/ssact/title18/1819.htm
• Nursing Home Reform Act — 42 U.S.C. § 1396r (Medicaid): https://www.ssa.gov/OP_Home/ssact/title19/1919.htm
• 42 C.F.R. Part 483 (Requirements for States and Long-Term Care Facilities): 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/current/title-42/section-483.10
• 42 C.F.R. § 483.12 (Freedom from abuse, neglect, exploitation): https://www.ecfr.gov/current/title-42/section-483.12
• 42 C.F.R. § 483.15 (Admission, transfer, discharge): https://www.ecfr.gov/current/title-42/section-483.15
• 42 C.F.R. § 483.24 / § 483.25 (Quality of life / quality of care): https://www.ecfr.gov/current/title-42/section-483.24
• 42 C.F.R. Part 488 (Survey, certification, enforcement): https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-488
• Older Americans Act — Long-Term Care Ombudsman, 42 U.S.C. § 3058g: https://www.acl.gov/programs/Protecting-Rights-and-Preventing-Abuse/Long-term-Care-Ombudsman-Program

South Dakota authority:

• SDCL Chapter 34-12 (Health and Health Care Facilities): https://sdlegislature.gov/Statutes/34-12
• SDCL § 34-12-67 (Visitation): https://sdlegislature.gov/Statutes/34-12-67
• SDCL Chapter 34-12D: https://sdlegislature.gov/Statutes/34-12D
• SDCL Chapter 22-46 (Abuse / neglect / exploitation): https://sdlegislature.gov/Statutes/22-46
• ARSD Article 44:73 (Nursing facilities): https://sdlegislature.gov/Rules/Rule/44:73
• ARSD Article 44:70 (Assisted living centers): https://sdlegislature.gov/Rules/Rule/44:70

State agencies and complaint portals:

• South Dakota Department of Health — Long-Term Care: https://doh.sd.gov/topics/long-term-care/
• DOH Health Care Facilities Licensure & Certification — Complaints: https://doh.sd.gov/licensing-and-records/boards/nursing-facility-administrators/complaints/
• DOH Online Complaint Form: https://apps.sd.gov/PH91HcOsr/Website/CompFormOnline.aspx
• Long-Term Care Ombudsman / Dakota at Home: https://dakotaathome.sd.gov/ — 1-833-663-9673
• SD Department of Human Services LTSS: https://dhs.sd.gov/ltss/
• South Dakota Attorney General Consumer Protection: https://consumer.sd.gov/ — 1-800-300-1986

Federal portals:

• CMS Care Compare (nursing home ratings): https://www.medicare.gov/care-compare/
• CMS Region VIII (Denver): https://www.cms.gov/about-cms/agency-information/regional-offices

Reference (verify against primary sources):

• South Dakota nursing home complaint guide (third-party): https://nursinghomecomplaint.org/resources/south-dakota-nursing-home-complaint/
• LTC Ombudsman Resource Center: https://ltcombudsman.org/

This template is provided for informational purposes only and does not constitute legal advice. Filing channels, regulatory citations, and contact numbers should be verified against current South Dakota Department of Health, Department of Human Services, and CMS guidance before submission. Consult a licensed South Dakota attorney for litigation, administrative appeals, or formal enforcement actions.