Virginia Nursing Home Resident Complaint — Long-Term Care Ombudsman and VDH Office of Licensure and Certification

VIRGINIA NURSING HOME RESIDENT COMPLAINT — LONG-TERM CARE OMBUDSMAN AND VDH OFFICE OF LICENSURE AND CERTIFICATION

TABLE OF CONTENTS

1. Routing and Filing Cover Page
2. Complainant Information
3. Resident Information
4. Facility Information
5. Statutory and Regulatory Basis
6. Nature of the Complaint
7. Detailed Allegations and Narrative
8. Internal Grievance Process Used
9. Resident Rights Implicated
10. Evidence and Witnesses
11. Harm and Requested Relief
12. Confidentiality, Retaliation, and Authorization
13. Complainant Certification and Signature
14. Virginia Practice Notes
15. Sources and References

1. ROUTING AND FILING COVER PAGE

Date: [__/__/____]

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

• ☐ Virginia State Long-Term Care Ombudsman — 1-800-552-5019; statelt​[email protected]
• ☐ Local Long-Term Care Ombudsman — Region: [________]; Name: [________]; Phone: [________]
• ☐ VDH Office of Licensure and Certification (OLC) — Complaint Unit
• Toll-free: 1-800-955-1819
• Metro Richmond: (804) 367-2106
• Email: [email protected]
• Mail: 9960 Mayland Drive, Suite 401, Henrico, VA 23233-1463
• ☐ CMS Region III (Medicare/Medicaid-certified facility) — for federal NHRA enforcement
• ☐ Virginia Adult Protective Services (APS) — 1-888-832-3858 (also file APS Report)
• ☐ Office of the Attorney General — Medicaid Fraud Control Unit (resident-on-resident or staff abuse, neglect, financial exploitation in Medicaid-funded facilities)
• ☐ Local Law Enforcement — Department: [________], Case #: [________]
• ☐ Virginia Board of Nursing / Board of Long-Term Care Administrators — for licensee conduct

Confidentiality requested: ☐ Yes — keep complainant's identity confidential to the extent permitted by law ☐ No

2. COMPLAINANT INFORMATION

3. RESIDENT INFORMATION

4. FACILITY INFORMATION

5. STATUTORY AND REGULATORY BASIS

This complaint invokes, without limitation:

• Federal Nursing Home Reform Act (NHRA), 42 U.S.C. §§ 1395i-3 and 1396r, and the Federal Requirements of Participation, 42 C.F.R. Part 483, Subpart B, including:
• § 483.10 (Resident rights)
• § 483.12 (Freedom from abuse, neglect, and exploitation)
• § 483.15 (Admission, transfer, and discharge rights)
• § 483.21 (Comprehensive person-centered care planning)
• § 483.24 (Quality of life)
• § 483.25 (Quality of care; pressure ulcers, falls, hydration, medication errors)
• § 483.40 (Behavioral health services)
• § 483.45 (Pharmacy services and unnecessary drugs / chemical restraints)
• § 483.70 (Administration)
• § 483.95 (Training)
• Va. Code § 32.1-138 (enumerated patient rights, posting, training, certification of compliance)
• Va. Code § 32.1-138.1 and § 32.1-138.4 (transfer and discharge rights, notice)
• Va. Code § 32.1-138.6 (right to maintain a record of personal funds)
• 12 VAC 5-371 (Regulations for the Licensure of Nursing Facilities)
• Older Americans Act, 42 U.S.C. § 3058g, and Va. Code § 51.5-182 (Long-Term Care Ombudsman authority)

6. NATURE OF THE COMPLAINT

Check all that apply:

Care and Quality:

• ☐ Failure to provide care consistent with the resident's comprehensive care plan
• ☐ Pressure injuries / bedsores / wound mismanagement
• ☐ Falls / failure to assess fall risk / failure to provide assistive devices
• ☐ Dehydration / malnutrition / weight loss
• ☐ Medication errors / missed doses / wrong medication / wrong route
• ☐ Inappropriate use of antipsychotics or chemical restraints (42 C.F.R. § 483.45)
• ☐ Inappropriate use of physical restraints (12 VAC 5-371-330)
• ☐ Failure to provide mental-health or behavioral-health services
• ☐ Inadequate hygiene, toileting, mouth care, grooming
• ☐ Failure to follow physician orders
• ☐ Failure to notify physician or family of significant change in condition

Abuse, Neglect, Exploitation:

• ☐ Physical, sexual, mental, or verbal abuse by staff
• ☐ Resident-on-resident abuse (failure to supervise / intervene)
• ☐ Financial exploitation; misuse of resident trust funds (12 VAC 5-371-160)
• ☐ Theft of personal property
• ☐ Misappropriation of property as defined in 42 C.F.R. § 483.5

Resident Rights / Dignity:

• ☐ Failure to provide notice of rights upon admission
• ☐ Restriction on visitation (including post-PHE / OBRA visitation rights)
• ☐ Restriction on access to personal mail, telephone, or electronic communications
• ☐ Failure to honor advance directives, DNR, or POLST
• ☐ Discrimination on basis of payer source, race, national origin, disability, sexual orientation, or gender identity
• ☐ Retaliation against resident or family for raising concerns

Transfer / Discharge:

• ☐ Involuntary transfer or discharge without proper notice (Va. Code § 32.1-138.1; § 32.1-138.4; 42 C.F.R. § 483.15)
• ☐ Improper "dumping" to hospital, shelter, or boarding house
• ☐ Failure to readmit after hospitalization (bed-hold violation)
• ☐ Discharge without safe and orderly plan

Staffing and Operations:

• ☐ Insufficient nurse staffing per 42 C.F.R. § 483.35 / current federal staffing rule
• ☐ Failure to perform required pre-employment checks / Nurse Aide Registry
• ☐ Failure to investigate or report alleged violations to OLC and APS within statutory timeframes
• ☐ Falsification of records (MAR, ADL, charting, time records)

Environmental / Life-Safety:

• ☐ Unsanitary conditions / pest infestation
• ☐ Building, fire, or life-safety code violations
• ☐ Inadequate temperature control
• ☐ Inadequate emergency preparedness or staffing during emergencies

Billing / Trust Funds:

• ☐ Improper resident trust account handling (12 VAC 5-371-160)
• ☐ Improper Medicaid patient-pay collection
• ☐ Unauthorized charges to resident or family

7. DETAILED ALLEGATIONS AND NARRATIVE

7.1. Date(s) of incident(s). [________________________________]

7.2. Time(s) and location(s) within the facility. [________________________________]

7.3. Staff involved (names and titles, if known). [________________________________]

7.4. Detailed narrative. Describe what happened, in chronological order, using observable facts. Quote the resident's own statements where possible. Identify each rule, regulation, or statute violated.

[NARRATIVE — capture (a) the conduct or omission; (b) how it deviated from the care plan or applicable rule; (c) the resident's resulting injury, condition change, or rights violation; (d) the facility's response to internal grievance; and (e) the impact on the resident. Cite specific entries in the medical record, MAR, or care plan where possible.]

7.5. Pattern. Is this ☐ a single incident ☐ ongoing ☐ recurrent ☐ escalating?

7.6. Resident's current status. [________________________________]

8. INTERNAL GRIEVANCE PROCESS USED

8.1. Did the complainant raise this concern with the facility before filing? ☐ Yes ☐ No

8.2. If yes, identify each contact:

8.3. Grievance Officer. Pursuant to 42 C.F.R. § 483.10(j), the facility must designate a Grievance Official. Name (if known): [________________________________].

8.4. Written grievance response received? ☐ Yes (attached) ☐ No ☐ Inadequate.

9. RESIDENT RIGHTS IMPLICATED

The complainant alleges violation of one or more of the following resident rights (check all that apply):

• ☐ Right to be free from abuse, neglect, and exploitation (42 C.F.R. § 483.12; Va. Code § 32.1-138)
• ☐ Right to dignified existence and self-determination (42 C.F.R. § 483.10(a))
• ☐ Right to be informed of medical condition and to participate in care planning (Va. Code § 32.1-138(1))
• ☐ Right to refuse treatment and refuse experimental research (Va. Code § 32.1-138(1); 42 C.F.R. § 483.10(c))
• ☐ Right to be transferred or discharged only for medical reasons, welfare of self or others, or nonpayment, with reasonable advance written notice (Va. Code § 32.1-138(2); § 32.1-138.1; § 32.1-138.4; 42 C.F.R. § 483.15)
• ☐ Right to voice grievances without reprisal (Va. Code § 32.1-138(3); 42 C.F.R. § 483.10(j))
• ☐ Right to be free from physical and chemical restraints not authorized by physician (12 VAC 5-371-330; 42 C.F.R. § 483.12; § 483.45)
• ☐ Right to manage personal finances and to an itemized accounting of personal funds held by the facility (12 VAC 5-371-160; 42 C.F.R. § 483.10(f)(10))
• ☐ Right to confidentiality of personal and clinical records (42 C.F.R. § 483.10(h))
• ☐ Right to organize and participate in resident and family councils (42 C.F.R. § 483.10(f)(5))
• ☐ Right to receive visitors of the resident's choosing, including the Long-Term Care Ombudsman (42 C.F.R. § 483.10(f)(4); Va. Code § 51.5-182)
• ☐ Right to be free from discrimination in admissions on the basis of payer source for Medicaid-certified beds
• ☐ Right to a safe, clean, comfortable, homelike environment (42 C.F.R. § 483.10(i))
• ☐ Right to access to records (42 C.F.R. § 483.10(g))

10. EVIDENCE AND WITNESSES

10.1. Documents attached or available. ☐ check all that apply:

• ☐ Care plan / MDS assessments — Tab [____]
• ☐ Medication Administration Record (MAR) — Tab [____]
• ☐ Treatment Administration Record (TAR) — Tab [____]
• ☐ Physician orders / progress notes — Tab [____]
• ☐ Nursing notes / ADL flow sheets — Tab [____]
• ☐ Incident / accident reports — Tab [____]
• ☐ Photographs of injuries or conditions (with consent) — Tab [____]
• ☐ Resident trust account statements — Tab [____]
• ☐ Billing statements / Medicaid patient-pay calculations — Tab [____]
• ☐ Admission agreement / arbitration disclosure — Tab [____]
• ☐ Grievance correspondence — Tab [____]
• ☐ Discharge / transfer notice and bed-hold notice — Tab [____]
• ☐ CMS-2567 prior survey deficiency citations (Care Compare) — Tab [____]
• ☐ Resident or family written statements — Tab [____]

10.2. Witnesses.

11. HARM AND REQUESTED RELIEF

11.1. Harm to the resident. Describe physical, emotional, financial, or rights-based harm. Include hospitalization, ER visits, weight loss, skin breakdown, infection, fractures, expressions of fear, or financial loss.

[________________________________]

11.2. Requested relief from OLC.

• ☐ Onsite complaint investigation (with offer of resident interview)
• ☐ Issuance of CMS-2567 deficiency citations
• ☐ Civil monetary penalty (CMP)
• ☐ Directed plan of correction / directed in-service training
• ☐ Denial of payment for new admissions (DPNA)
• ☐ Termination of provider agreement / license revocation in cases of immediate jeopardy
• ☐ Referral to CMS Region III, Office of Inspector General, or Medicaid Fraud Control Unit
• ☐ Coordination with APS (1-888-832-3858)

11.3. Requested relief from the Long-Term Care Ombudsman.

• ☐ Resident-centered advocacy and problem-solving
• ☐ Mediation with facility administration
• ☐ Care-plan meeting attendance
• ☐ Assistance contesting transfer/discharge before the state hearing officer
• ☐ Referral to legal services

11.4. Other regulatory referrals.

• ☐ Virginia Board of Nursing — for licensee conduct
• ☐ Virginia Board of Long-Term Care Administrators — for administrator conduct
• ☐ Virginia Department of Health Professions — for other health professionals
• ☐ Office of the Attorney General — Medicaid Fraud Control Unit

12. CONFIDENTIALITY, RETALIATION, AND AUTHORIZATION

12.1. Ombudsman confidentiality. The Long-Term Care Ombudsman is bound by federal confidentiality requirements (45 C.F.R. § 1324.11) and Virginia law to maintain the confidentiality of resident and complainant identities, except with informed consent or as authorized by law.

12.2. OLC confidentiality. OLC is required to maintain confidentiality of complainant identity to the extent permitted by Virginia law and federal CMS rules.

12.3. Anti-retaliation. Federal and Virginia law prohibit retaliation against a resident, family member, or staff member for filing a complaint or cooperating with an investigation. See 42 C.F.R. § 483.10(j)(4); Va. Code § 32.1-138; Va. Code § 40.1-27.3 (general public-policy retaliation).

12.4. HIPAA / Records Authorization. Complainant ☐ attaches ☐ does not attach a HIPAA-compliant authorization (45 C.F.R. § 164.508) permitting OLC and the Ombudsman to access the resident's protected health information for purposes of this complaint. The Ombudsman has independent access rights to records under 42 U.S.C. § 3058g(b)(1)(B) with resident consent.

13. COMPLAINANT CERTIFICATION AND SIGNATURE

I certify under penalty of perjury under the laws of the Commonwealth of Virginia that the information contained in this complaint is true and correct to the best of my knowledge, and that I am filing this complaint in good faith.

Date: [__/__/____]

[________________________________]

[COMPLAINANT NAME]

Title / Capacity: [________________________________]

If the complainant is the resident:

[________________________________]

[RESIDENT SIGNATURE]

(If the resident is unable to sign, identify the basis for filing without signature, such as cognitive impairment or fear of retaliation, and identify the legal representative or authority for filing.)

14. VIRGINIA PRACTICE NOTES

• Three Parallel Tracks. A nursing-home concern in Virginia is most effectively addressed by filing simultaneously with: (a) the Long-Term Care Ombudsman (advocacy/mediation), (b) VDH Office of Licensure and Certification (regulatory enforcement), and (c) APS (where abuse, neglect, or exploitation is suspected).
• OLC Is the State Survey Agency. For Medicare/Medicaid-certified facilities, OLC conducts complaint investigations under contract with CMS. Findings issue on CMS Form 2567. Severity and scope determine enforcement remedies, up to and including federal termination.
• Transfer and Discharge Notice. Va. Code § 32.1-138.4 generally requires at least 30 days' advance written notice for involuntary transfer or discharge, with limited emergency exceptions, and notice of appeal rights. Federal law adds parallel requirements at 42 C.F.R. § 483.15(c). Resident-initiated appeals are heard by the state hearing system.
• Bed-Hold Notice. Facilities must provide written bed-hold and readmission policies; Medicaid-certified facilities must readmit residents from hospitalization to the next available bed under federal and Virginia rules.
• Restraints. Both physical and chemical restraints are prohibited unless required to treat the resident's medical symptoms with documented physician order and least-restrictive-alternative analysis (12 VAC 5-371-330; 42 C.F.R. §§ 483.12 and 483.45).
• Resident Trust Funds. Facilities holding resident funds must comply with 12 VAC 5-371-160 and 42 C.F.R. § 483.10(f)(10), including separate accounting, quarterly statements, and bonding.
• Care Compare / CMS-2567. Five-Star ratings and historical deficiency citations are publicly available on the CMS Care Compare website and inform the OLC complaint-prioritization process.
• Posting. Va. Code § 32.1-138 requires that resident rights and complaint contact information (including Ombudsman and OLC) be posted in 12-point type in a conspicuous public place in the facility.
• Ombudsman Access. Ombudsmen have statutory rights of access to facilities, residents, and (with consent) records under the Older Americans Act and Va. Code § 51.5-182. Facility interference may itself constitute a regulatory violation.
• Litigation Considerations. A regulatory complaint does not toll civil statutes of limitation. Where injury, wrongful death, or financial loss has occurred, consult counsel promptly.

15. SOURCES AND REFERENCES

• VDH Office of Licensure and Certification — File a Complaint — https://www.vdh.virginia.gov/licensure-and-certification/file-a-complaint/
• Virginia State Long-Term Care Ombudsman — https://www.elderrights.virginia.gov/
• Virginia DARS Ombudsman Program — https://www.elderrights.virginia.gov/solving.htm
• 42 C.F.R. Part 483, Subpart B (Federal Requirements of Participation) — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B
• 42 U.S.C. § 1395i-3 / § 1396r (Nursing Home Reform Act) — https://www.govinfo.gov/
• 42 U.S.C. § 3058g (State Long-Term Care Ombudsman Program) — https://www.govinfo.gov/
• 45 C.F.R. § 1324 (Ombudsman regulations) — https://www.ecfr.gov/
• Va. Code Title 32.1, Chapter 5, Article 2 (Patient Rights in Nursing Homes) — https://law.lis.virginia.gov/vacodefull/title32.1/chapter5/article2/
• Va. Code § 32.1-138 — https://law.lis.virginia.gov/vacode/title32.1/chapter5/section32.1-138/
• Va. Code § 32.1-138.1 — https://law.lis.virginia.gov/vacode/title32.1/chapter5/section32.1-138.1/
• 12 VAC 5-371 (Nursing Facility Licensure Regulations) — https://law.lis.virginia.gov/admincode/title12/agency5/chapter371/
• 12 VAC 5-371-150 (Resident rights) — https://law.lis.virginia.gov/admincode/title12/agency5/chapter371/section150/
• CMS Care Compare — https://www.medicare.gov/care-compare/
• Virginia Adult Protective Services Hotline — 1-888-832-3858 (24 hours) — https://www.dars.virginia.gov/aps/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Filing a regulatory complaint does not toll civil statutes of limitation. An attorney licensed in Virginia should review fact-specific applications, especially those involving wrongful discharge, neglect-related injury, financial exploitation, or contemplated litigation.