Vermont Nursing Home Resident Complaint (Long-Term Care Ombudsman / DLP Survey & Certification)

VERMONT NURSING HOME RESIDENT COMPLAINT

TABLE OF CONTENTS

1. Addressee and Filing Route
2. Complainant Information
3. Resident Information
4. Facility Information
5. Statutory and Regulatory Rights at Issue
6. Statement of Complaint
7. Specific Incidents Timeline
8. Internal Resolution Attempted
9. Witnesses, Evidence, and Records
10. Harm and Remedy Requested
11. Concurrent Filings and Notifications
12. Authorization, Confidentiality, and Anti-Retaliation
13. Certification and Signature
14. Vermont Practice Notes
15. Sources and References

1. ADDRESSEE AND FILING ROUTE

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

• ☐ Vermont Long-Term Care Ombudsman Program (SLTCOP) — Vermont Legal Aid, 264 North Winooski Avenue, Burlington, VT 05401 | Tel: 1-800-889-2047 ext. 3 | Web: https://www.vtlegalaid.org/legal-projects/long-term-care-ombudsman.
• ☐ Vermont Division of Licensing and Protection — Survey & Certification (State Survey Agency) — HC 2 South, 280 State Drive, Waterbury, VT 05671-2060 | Tel: 1-888-700-5330 | Web: https://dlp.vermont.gov/survey-cert/sc-complaints.
• ☐ Vermont Adult Protective Services (APS) — HC 2 South, 280 State Drive, Waterbury, VT 05671-2020 | Tel: 1-800-564-1612 | Web: https://dlp.vermont.gov/aps/make-aps-report.
• ☐ CMS Region 1 Boston (federal escalation, after exhausting state remedies) — JFK Federal Building, Boston, MA.

Filing date: [__/__/____].

2. COMPLAINANT INFORMATION

3. RESIDENT INFORMATION

4. FACILITY INFORMATION

5. STATUTORY AND REGULATORY RIGHTS AT ISSUE

Complainant alleges the facility violated one or more of the following resident rights (check all that apply):

5.1. Federal Nursing Home Reform Act — 42 C.F.R. § 483.10 et seq.

• ☐ § 483.10 — Right to dignity, self-determination, and information;
• ☐ § 483.10(c) — Planning and implementing care; right to participate in care planning;
• ☐ § 483.10(e) — Privacy and confidentiality;
• ☐ § 483.10(g) — Information and communication, including access to records within 24/2-business-day windows;
• ☐ § 483.10(h) — Privacy in written and telephonic communication and visitation;
• ☐ § 483.10(j) — Grievances; right to file without retaliation; required grievance officer;
• ☐ § 483.12 — Freedom from abuse, neglect, and exploitation; mandatory reporting under § 483.12(c);
• ☐ § 483.15 — Admission, transfer, and discharge rights; 30-day written notice; appeal to Vermont Human Services Board;
• ☐ § 483.21 — Comprehensive person-centered care planning;
• ☐ § 483.24 — Quality of life (ADLs, mobility, activities);
• ☐ § 483.25 — Quality of care (pressure injuries, falls, hydration, incontinence, range of motion, medication management, pain management);
• ☐ § 483.30 — Physician services;
• ☐ § 483.35 — Nursing services and sufficient staffing;
• ☐ § 483.40 — Behavioral health services;
• ☐ § 483.45 — Pharmacy services; psychotropic / antipsychotic chemical-restraint review;
• ☐ § 483.50 — Laboratory, radiology, and other diagnostic services;
• ☐ § 483.55 — Dental services;
• ☐ § 483.60 — Food and nutrition services;
• ☐ § 483.70 — Administration;
• ☐ § 483.80 — Infection control.

5.2. Vermont Nursing Home Residents' Bill of Rights — 33 V.S.A. § 7301.

• ☐ Right to be fully informed of rights, rules, services, and charges in writing prior to admission and during stay;
• ☐ Right to be informed of medical condition and to participate in treatment planning;
• ☐ Right to choose personal physician and seek a second opinion;
• ☐ Right to refuse care or treatment, including the right to discharge oneself, after being informed of consequences;
• ☐ Right to manage personal financial affairs (with quarterly accounting if delegated);
• ☐ Right to be free from mental and physical abuse and free from chemical and (except in emergencies) physical restraints;
• ☐ Right to confidentiality of medical records;
• ☐ Right to be treated with consideration, respect, and full recognition of dignity;
• ☐ Right to private telephone access in a quiet area;
• ☐ Right to send and receive private mail;
• ☐ Right to associate with persons and groups of the resident's choice and to receive visitors privately;
• ☐ Right to retain personal clothing and possessions;
• ☐ Right of married residents to share a room (where both are residents);
• ☐ Right to bed-hold during hospitalization (up to 10 days);
• ☐ Right to voice grievances without fear of reprisal or discrimination;
• ☐ Right to participate in resident and family councils with provided meeting space;
• ☐ Right to access facility inspection (CMS Form 2567) reports;
• ☐ Right to professional pain assessment and management.

5.3. Vermont Licensing & Operating Rules — 13-110-005 Code Vt. R. (and 13-110-009 for residential care homes).

• ☐ Staffing standards;
• ☐ Care planning;
• ☐ Medication administration;
• ☐ Physical environment / sanitation;
• ☐ Reporting of resident incidents and unusual occurrences.

5.4. Vulnerable Adult Protections — 33 V.S.A. Chapter 69. ☐ Conduct constitutes abuse, neglect, or exploitation of a vulnerable adult, requiring concurrent APS report (see Section 11).

6. STATEMENT OF COMPLAINT

6.1. Summary. Complainant alleges that on or about [__/__/____] and continuing thereafter, the facility identified in Section 4 violated the rights and standards identified in Section 5 with respect to the resident identified in Section 3. The conduct includes (check all that apply):

• ☐ Insufficient staffing leading to delayed call-bell response, missed cares, or unsafe transfers;
• ☐ Failure to develop, update, or follow the comprehensive care plan;
• ☐ Failure to prevent or treat avoidable pressure injuries;
• ☐ Falls without adequate fall-risk assessment, intervention, or post-fall analysis;
• ☐ Medication errors, omissions, or unauthorized chemical restraint with antipsychotic medication;
• ☐ Use of physical restraints not authorized for medical symptoms;
• ☐ Dehydration, malnutrition, unplanned weight loss;
• ☐ Inadequate incontinence care, failure to toilet, skin breakdown;
• ☐ Inadequate pain assessment or management;
• ☐ Inadequate infection control;
• ☐ Elopement / wandering without adequate supervision;
• ☐ Resident-on-resident abuse or assault;
• ☐ Staff-on-resident abuse, neglect, or exploitation;
• ☐ Sexual abuse or inappropriate sexual contact;
• ☐ Financial exploitation, theft of personal property, misuse of resident-fund account;
• ☐ Improper discharge / transfer or threat thereof without 30-day notice and appeal rights;
• ☐ Failure to honor advance directive, DNR, COLST / POLST;
• ☐ Retaliation against resident, family, or staff for raising concerns;
• ☐ Failure to provide grievance officer or respond to grievances within required timeframes;
• ☐ Failure to allow resident or family council;
• ☐ Failure to post Bill of Rights, complaint contact information, or most recent survey results;
• ☐ Other: [____________].

6.2. Narrative.

[________________________________]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

7. SPECIFIC INCIDENTS TIMELINE

8. INTERNAL RESOLUTION ATTEMPTED

8.1. Facility Grievance Process. ☐ Yes — grievance filed with grievance officer on [__/__/____]; written response received [__/__/____]; ☐ No response received within required time; ☐ No — facility did not provide grievance officer information.

8.2. Care Conference / Care Plan Meeting. ☐ Held on [__/__/____]; concerns raised: [____________]; outcome: [____________].

8.3. Discussion with Administrator / DON. ☐ Yes — date [__/__/____]; participants [____________]; outcome [____________]. ☐ No.

8.4. Resident or Family Council. ☐ Issue raised on [__/__/____]; ☐ No council exists.

8.5. Reason Internal Resolution Was Inadequate. [________________________________].

9. WITNESSES, EVIDENCE, AND RECORDS

Records and Evidence Available:

• ☐ Resident's medical chart / EHR;
• ☐ MDS 3.0 assessments;
• ☐ Care plan and updates;
• ☐ Medication Administration Record (MAR);
• ☐ Treatment Administration Record (TAR);
• ☐ Nursing notes / progress notes;
• ☐ Physician orders;
• ☐ Incident / accident reports;
• ☐ Body audit / skin assessment;
• ☐ Photographs of injuries (with measuring reference);
• ☐ Wound care records;
• ☐ Fall logs and post-fall huddle notes;
• ☐ Staffing schedules / posted daily staffing;
• ☐ Resident-fund account statements;
• ☐ Surveillance video;
• ☐ Family text / email correspondence with facility;
• ☐ Prior CMS 2567 survey citations;
• ☐ Other: [____________].

Records Requested by Resident / Representative: Pursuant to 42 C.F.R. § 483.10(g)(2), the resident is entitled to inspect records within 24 hours and receive a copy within 2 business days. Request submitted to facility on [__/__/____]; response: [____________].

10. HARM AND REMEDY REQUESTED

10.1. Harm to Resident.

• ☐ Physical injury (describe): [____________];
• ☐ Emotional / psychological harm: [____________];
• ☐ Financial loss: $[__________];
• ☐ Loss of dignity, autonomy, or rights;
• ☐ Hospitalization required: ☐ Yes — date [__/__/____] at [____________] hospital ☐ No;
• ☐ Death: ☐ Yes — date [__/__/____] (concurrent reporting to Office of the Chief Medical Examiner and law enforcement may apply) ☐ No;
• ☐ Other: [____________].

10.2. Relief Requested from Ombudsman.

• ☐ Investigation and resolution on behalf of resident;
• ☐ Care-conference attendance;
• ☐ Mediation with facility administration;
• ☐ Advocacy regarding discharge / transfer appeal before Human Services Board;
• ☐ Advice and information regarding resident rights;
• ☐ Referral to legal services;
• ☐ Other: [____________].

10.3. Relief Requested from DLP Survey & Certification.

• ☐ On-site complaint survey of facility;
• ☐ Citation of regulatory deficiencies on CMS Form 2567;
• ☐ Imposition of remedies including but not limited to: civil money penalty (CMP); denial of payment for new admissions (DPNA); directed plan of correction (DPOC); directed in-service training; state monitoring; temporary management; ban on admissions; license suspension or revocation;
• ☐ Referral to CMS Region 1 for federal enforcement;
• ☐ Other: [____________].

10.4. Relief Requested from APS.

• ☐ Investigation of alleged abuse, neglect, or exploitation under 33 V.S.A. § 6905;
• ☐ Substantiation determination and placement on Vermont Adult Abuse Registry where warranted (33 V.S.A. § 6911);
• ☐ Coordination with law enforcement and State's Attorney for prosecution under 13 V.S.A. § 1375 et seq.;
• ☐ Petition for relief from abuse of vulnerable adults under 33 V.S.A. § 6933.

10.5. Reservation of Rights. Complainant reserves all rights under 33 V.S.A. § 7306 (private right of action for violation of resident's rights) and any other applicable statute, regulation, or common-law cause of action including negligence, battery, false imprisonment, intentional infliction of emotional distress, and wrongful death.

11. CONCURRENT FILINGS AND NOTIFICATIONS

• ☐ Vermont Long-Term Care Ombudsman: [__/__/____] | reference: [____________];
• ☐ DLP Survey & Certification: [__/__/____] | reference: [____________];
• ☐ Vermont APS: [__/__/____] | reference: [____________];
• ☐ Local law enforcement / Vermont State Police: [__/__/____] | report no.: [____________];
• ☐ Vermont State's Attorney ([____________] County): [__/__/____];
• ☐ Vermont Office of the Attorney General — Medicaid Fraud and Residential Abuse Unit: [__/__/____];
• ☐ Vermont Board of Nursing / professional licensing board: [__/__/____];
• ☐ CMS Region 1 (Boston): [__/__/____];
• ☐ Resident's primary physician / health-care agent: [__/__/____];
• ☐ Resident's family / Council member: [__/__/____].

12. AUTHORIZATION, CONFIDENTIALITY, AND ANTI-RETALIATION

12.1. Confidentiality. Ombudsman and APS records are confidential under federal and Vermont law. The Ombudsman may not disclose the identity of the complainant or the resident without the resident's (or legal representative's) consent except as required by law (Older Americans Act, 42 U.S.C. § 3058g(d); 33 V.S.A. § 6906). DLP S&C complaints are likewise treated as confidential to the extent permitted by law.

12.2. HIPAA Authorization. Resident or representative authorizes the facility, treating providers, and pharmacies to release protected health information to the Ombudsman, DLP, and APS as necessary for investigation:

Resident / Representative Signature: [________________________________]

Print Name and Capacity: [________________________________]

Date: [__/__/____]

12.3. Anti-Retaliation. Federal law (42 C.F.R. § 483.12(a)(4); § 483.10(j)(4)) and Vermont law (33 V.S.A. § 7301; 33 V.S.A. § 6912) prohibit any retaliation against a resident, family member, employee, or other person for filing a good-faith complaint or grievance. Retaliation is itself a separately actionable violation.

12.4. No Investigator Role. Complainant understands that the Ombudsman, DLP, and APS will conduct the investigation; complainant should NOT confront the alleged wrongdoer, alter records, or attempt independent investigation.

13. CERTIFICATION AND SIGNATURE

I declare under penalty of perjury under the laws of the State of Vermont that the foregoing is true and correct to the best of my knowledge, information, and belief, and that this complaint is filed in good faith.

Complainant Signature: [________________________________]

Print Name: [COMPLAINANT NAME]

Date: [__/__/____]

Resident Signature (if able and willing): [________________________________]

Print Name: [RESIDENT NAME]

Date: [__/__/____]

Attorney Signature (if represented): [________________________________]

[ATTORNEY NAME], Vermont Bar No. [####]

Counsel for Resident / Complainant

[STREET ADDRESS] | [CITY, VT ZIP] | Tel: [__________] | Email: [__________]

14. VERMONT PRACTICE NOTES

• Choosing the right route. Use the Ombudsman first for quality-of-care, dignity, and rights issues that the resident wants resolved through advocacy and mediation. Use DLP S&C for serious or systemic regulatory violations that warrant on-site survey and federal/state enforcement remedies. Use APS for any allegation of abuse, neglect, or exploitation. The three routes are NOT mutually exclusive; serious cases warrant simultaneous filings.
• Resident-directed advocacy. The State Long-Term Care Ombudsman is a resident-directed advocate under the Older Americans Act. The Ombudsman will not act over the resident's expressed objection where the resident has capacity. Family members frustrated by this constraint should consider DLP and APS routes if the conduct meets those thresholds.
• Discharge / transfer appeals. Involuntary discharge requires 30 days' written notice, statement of reason limited to the six federal grounds (42 C.F.R. § 483.15(c)(1)), and the right to appeal to the Vermont Human Services Board (3 V.S.A. Chapter 25). Appeals MUST be timely; the Ombudsman can assist with hearing preparation.
• Adult Abuse Registry. Substantiated APS findings against caregivers may result in placement on the Vermont Adult Abuse Registry, barring future caregiver employment in licensed settings.
• Vermont Bill of Rights enforcement. 33 V.S.A. § 7306 historically provides for a private right of action for violation of residents' rights. Verify the operative version of § 7306 and any associated remedies (injunctive relief, damages, attorneys' fees) before pleading a stand-alone statutory claim, as Title 33, Chapter 73 has been amended over time.
• Survey access. Posted CMS Form 2567 ("Statement of Deficiencies and Plan of Correction") for the most recent standard survey is publicly available at the facility and on DLP's website. Reviewing prior 2567s often reveals patterns relevant to a current complaint.
• Federal escalation. If state-level remedies are inadequate, complaints may be referred to CMS Region 1 (Boston) and, for Medicaid fraud or systemic resident neglect, to the Vermont Attorney General's Medicaid Fraud and Residential Abuse Unit.
• Coordination with civil litigation. Filing a regulatory complaint does NOT toll the statute of limitations on a civil action for personal injury (3 years, 12 V.S.A. § 512), wrongful death (2 years, 14 V.S.A. § 1492), or other torts. Coordinate with counsel.
• Staffing-data resources. CMS's Care Compare Payroll-Based Journal staffing data and the most recent state-conducted standard survey provide objective evidence of staffing patterns and prior deficiencies — request and attach.

15. SOURCES AND REFERENCES

• Vermont Long-Term Care Ombudsman Project (Vermont Legal Aid): https://www.vtlegalaid.org/legal-projects/long-term-care-ombudsman
• Vermont Adult Services Division — State Long-Term Care Ombudsman Program: https://asd.vermont.gov/services/ltc-ombudsman-program
• Vermont Division of Licensing and Protection: https://dlp.vermont.gov/
• DLP Survey & Certification Complaints: https://dlp.vermont.gov/survey-cert/sc-complaints | 1-888-700-5330
• Vermont Adult Protective Services: https://dlp.vermont.gov/aps/make-aps-report | 1-800-564-1612
• Vermont Statutes — 33 V.S.A. § 7301 (Nursing Home Residents' Bill of Rights): https://legislature.vermont.gov/statutes/section/33/073/07301
• Vermont Statutes — 33 V.S.A. Chapter 71 (Licensing): https://legislature.vermont.gov/statutes/title/33
• Code of Vermont Rules — 13-110-005 (Licensing and Operating Rules for Nursing Homes): https://www.law.cornell.edu/regulations/vermont/13-005-Code-Vt-R-13-110-005-X
• 42 C.F.R. Part 483, Subpart B — Federal Long-Term Care Facility Requirements: https://www.ecfr.gov/current/title-42/part-483
• 42 U.S.C. § 1395i-3 / § 1396r — Nursing Home Reform Act: https://www.law.cornell.edu/uscode/text/42/1396r
• Older Americans Act — 42 U.S.C. § 3058g (State LTC Ombudsman Program): https://www.law.cornell.edu/uscode/text/42/3058g
• CMS Care Compare (facility-level survey results): https://www.medicare.gov/care-compare/
• The Consumer Voice — Vermont resources: https://theconsumervoice.org/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Vermont-licensed attorney should review and customize this complaint before submission, particularly where serious injury, death, or anticipated litigation is involved. Filing a regulatory or Ombudsman complaint does NOT toll the statute of limitations for any separate civil action.