Wisconsin Nursing Home Resident Complaint (Ombudsman / DQA)

WISCONSIN NURSING HOME RESIDENT COMPLAINT — OMBUDSMAN AND DQA

TABLE OF CONTENTS

1. Recipient Agency Selection
2. Resident Information
3. Complainant Information
4. Facility Information
5. Statement of Complaint
6. Resident Rights Implicated
7. Specific Allegations
8. Evidence and Documentation
9. Prior Attempts at Resolution
10. Requested Action and Remedies
11. Confidentiality and Authorization
12. Signature
13. Wisconsin Practice Notes
14. Sources and References

1. RECIPIENT AGENCY SELECTION

2. RESIDENT INFORMATION

3. COMPLAINANT INFORMATION

3.1. Complainant name: [________________________________]

3.2. Relationship to resident:

• ☐ Resident (self-filing);
• ☐ Spouse / domestic partner;
• ☐ Adult child;
• ☐ Power of attorney for health care;
• ☐ Power of attorney for finances;
• ☐ Guardian (Wis. Stat. ch. 54);
• ☐ Other family member: [________];
• ☐ Friend / advocate;
• ☐ Mandatory reporter / professional;
• ☐ Anonymous (DQA only — Ombudsman generally requires consent);
• ☐ Other: [________________________________].

3.3. Address: [________________________________]

3.4. Telephone: [________]

3.5. Email: [________________________________]

3.6. Best time / method to be contacted: [________________________________]

4. FACILITY INFORMATION

4.1. Facility legal name: [________________________________]

4.2. Facility "doing business as" name: [________________________________]

4.3. Address: [________________________________]

4.4. Telephone: [________]

4.5. Administrator's name (if known): [________________________________]

4.6. Director of Nursing (if known): [________________________________]

4.7. Facility license type:

• ☐ Skilled Nursing Facility (SNF) — Wis. Admin. Code DHS 132;
• ☐ Nursing Facility (NF) — Wis. Admin. Code DHS 132;
• ☐ Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) — Wis. Admin. Code DHS 134;
• ☐ Community-Based Residential Facility (CBRF) — Wis. Admin. Code DHS 83;
• ☐ Residential Care Apartment Complex (RCAC) — Wis. Admin. Code DHS 89;
• ☐ Adult Family Home (AFH) — Wis. Admin. Code DHS 88.

4.8. Medicare / Medicaid certification: ☐ Medicare ☐ Medicaid ☐ Dual ☐ Private only

4.9. Corporate owner / parent company: [________________________________]

5. STATEMENT OF COMPLAINT

5.1. Date(s) of incident(s): [__/__/____] to [__/__/____]

5.2. Time(s) of incident(s) (if applicable): [____ : ____]

5.3. Location within facility: [________________________________]

5.4. Staff involved (names, titles if known): [________________________________]

5.5. Witnesses:

5.6. Detailed narrative (use additional pages as needed):

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

6. RESIDENT RIGHTS IMPLICATED

Wisconsin nursing home residents are entitled, at minimum, to the following rights:

• ☐ Right to be free from physical, sexual, mental, and verbal abuse, corporal punishment, and involuntary seclusion (42 C.F.R. § 483.12);
• ☐ Right to be free from neglect, exploitation, and misappropriation of property (42 C.F.R. § 483.12);
• ☐ Right to dignity, respect, and self-determination (42 C.F.R. § 483.10);
• ☐ Right to freedom from physical or chemical restraints not required to treat medical symptoms (42 C.F.R. § 483.10(e); § 50.09(1)(j));
• ☐ Right to private and unrestricted communication with family, physicians, attorneys, and the Ombudsman (Wis. Stat. § 50.09(1)(a) and (g));
• ☐ Right to send and receive sealed mail without censorship (Wis. Stat. § 50.09(1)(a));
• ☐ Right to reasonable telephone access and privacy of communication (Wis. Stat. § 50.09(1)(a));
• ☐ Right to participate in care planning and to refuse treatment (42 C.F.R. § 483.10(c)(6); Wis. Stat. § 50.09(1)(c));
• ☐ Right to be informed of medical condition and treatment (Wis. Stat. § 50.09(1)(c));
• ☐ Right to access medical records (42 C.F.R. § 483.10(g)(2); Wis. Stat. § 146.83);
• ☐ Right to manage personal financial affairs and to a quarterly accounting of any facility-managed funds (42 C.F.R. § 483.10(f)(10); Wis. Stat. § 50.09(1)(k));
• ☐ Right to retain personal clothing and possessions (Wis. Stat. § 50.09(1)(i));
• ☐ Right to share a room with spouse or domestic partner if both are residents, absent medical contraindication (Wis. Stat. § 50.09(1)(b));
• ☐ Right to advance written notice of room change or transfer (Wis. Stat. § 50.09(1)(g));
• ☐ Right to advance written notice of transfer or discharge with explanation of alternatives, and to appeal (42 C.F.R. § 483.15; Wis. Admin. Code DHS 132.53);
• ☐ Right to voice grievances without retaliation and to prompt facility response (42 C.F.R. § 483.10(j); Wis. Stat. § 50.09(1)(g));
• ☐ Right to organize and participate in resident and family councils (42 C.F.R. § 483.10(f)(5)–(6));
• ☐ Right to access the Long-Term Care Ombudsman and to receive Ombudsman visitors (Wis. Stat. § 50.10; 42 C.F.R. § 483.10(g)(4)(i));
• ☐ Right to be free from work for the facility unless under written voluntary agreement (42 C.F.R. § 483.10(f)(7)).

7. SPECIFIC ALLEGATIONS

Check all that apply:

• ☐ Physical abuse (striking, rough handling);
• ☐ Sexual abuse;
• ☐ Verbal / emotional abuse;
• ☐ Neglect — pressure ulcers, dehydration, malnutrition;
• ☐ Neglect — falls and inadequate supervision;
• ☐ Neglect — failure to assist with hygiene, toileting, ambulation;
• ☐ Medication errors (wrong drug, wrong dose, missed doses);
• ☐ Improper use of physical or chemical restraints;
• ☐ Inappropriate antipsychotic / psychotropic medication;
• ☐ Theft or misappropriation of resident funds or personal property;
• ☐ Financial exploitation;
• ☐ Improper or retaliatory discharge / transfer;
• ☐ Failure to provide advance notice of transfer/discharge;
• ☐ Failure to develop or follow comprehensive care plan;
• ☐ Inadequate staffing levels;
• ☐ Infection-control failures;
• ☐ Failure to provide activities of daily living (ADL) assistance;
• ☐ Denial of access to Ombudsman, attorney, family, or clergy;
• ☐ Mail tampering or denial of telephone privacy;
• ☐ Retaliation against resident for filing grievance;
• ☐ Dietary failures (unsanitary meals, inadequate therapeutic diet);
• ☐ Building / safety code violations;
• ☐ Resident-to-resident abuse not addressed;
• ☐ Other: [________________________________].

8. EVIDENCE AND DOCUMENTATION

Available materials (attach copies; redact PHI as appropriate):

• ☐ Photographs (date-stamped);
• ☐ Medical records and progress notes;
• ☐ Medication administration records (MARs);
• ☐ Care plan and care-plan meeting notes;
• ☐ Incident / accident reports filed by facility;
• ☐ Grievance records and facility responses;
• ☐ Bank statements / personal-needs-account ledgers;
• ☐ Written notices of transfer or discharge;
• ☐ Witness statements;
• ☐ Audio / video recordings (verify Wisconsin two-party consent rules under § 968.31 — Wisconsin is a one-party consent state for audio recording of personal conversations);
• ☐ Correspondence with facility administration;
• ☐ Pharmacy records;
• ☐ Skin-integrity assessments;
• ☐ Falls assessments.

9. PRIOR ATTEMPTS AT RESOLUTION

9.1. Was the issue raised with facility staff? ☐ Yes ☐ No

9.2. Was the issue raised with the administrator or Director of Nursing? ☐ Yes ☐ No

9.3. Was a written grievance submitted under the facility's grievance procedure? ☐ Yes ☐ No Date: [__/__/____]

9.4. Has the facility responded? ☐ Yes ☐ No Substance: [________________________________]

9.5. Was the matter referred to the Long-Term Care Ombudsman? ☐ Yes ☐ No Date: [__/__/____]

9.6. Was a regulatory complaint previously filed with DQA? ☐ Yes ☐ No Tracking #: [________]

10. REQUESTED ACTION AND REMEDIES

Complainant requests that the receiving agency:

• ☐ Conduct an unannounced on-site inspection / complaint investigation under 42 C.F.R. § 488.332 and Wis. Stat. § 50.04;
• ☐ Issue Statements of Deficiencies (CMS Form 2567) for confirmed violations;
• ☐ Recommend or impose enforcement remedies under 42 C.F.R. § 488.406, including:
• ☐ Civil money penalties (per-day or per-instance);
• ☐ Directed plan of correction;
• ☐ Directed in-service training;
• ☐ State monitoring;
• ☐ Denial of payment for new admissions;
• ☐ Temporary management;
• ☐ Termination of Medicare and Medicaid provider agreements;
• ☐ Refer for criminal prosecution under Wis. Stat. § 940.295 (abuse/neglect of patients and residents) or § 940.285 (abuse of vulnerable adults);
• ☐ Refer to Wisconsin Caregiver Misconduct Registry under Wis. Admin. Code DHS 13;
• ☐ Refer for licensure action against individual licensed personnel through Department of Safety and Professional Services;
• ☐ Issue cease-and-desist regarding retaliatory or improper transfer / discharge;
• ☐ Coordinate Ombudsman advocacy on behalf of the resident;
• ☐ Report findings in writing to complainant within statutory time frames;
• ☐ Other: [________________________________].

11. CONFIDENTIALITY AND AUTHORIZATION

11.1. DQA confidentiality. DQA shall keep the complainant's identity confidential under Wis. Stat. § 50.135 except as necessary to investigate or as required by law. The resident's identity may also be protected upon request.

11.2. Ombudsman confidentiality. Pursuant to 45 C.F.R. § 1324.11(e)(3) and Wis. Stat. § 16.009, the Ombudsman shall not disclose identifying information about a resident or complainant without informed consent or court order.

11.3. Resident consent (Ombudsman pathway). I, the resident or authorized representative, authorize the Ombudsman to:

• ☐ Investigate the matters described herein;
• ☐ Communicate with facility staff and DQA on my behalf;
• ☐ Disclose my identity to the facility as necessary to advocate;
• ☐ Withhold my identity from the facility.

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

11.4. Anti-retaliation. Federal and Wisconsin law prohibit retaliation against a resident or representative for filing a complaint or contacting the Ombudsman. See 42 C.F.R. § 483.10(j)(4); Wis. Stat. § 50.07; Wis. Stat. § 146.997 (health care worker protection).

12. SIGNATURE

I certify that the information set forth above is true and correct to the best of my knowledge and submitted in good faith.

Complainant signature: [________________________________]

Print name: [________________________________]

Date: [__/__/____]

Time: [____ : ____]

13. WISCONSIN PRACTICE NOTES

• Two parallel pathways. The Long-Term Care Ombudsman (1-800-815-0015) provides advocacy and informal resolution. DQA (1-800-642-6552) provides regulatory enforcement. Filing with one does not bar filing with the other; coordinated filing is often most effective.
• Federal NHRA framework. Federal nursing home requirements at 42 U.S.C. § 1395i-3 (Medicare) and § 1396r (Medicaid), implemented at 42 C.F.R. Part 483 Subpart B, establish minimum care, staffing, and resident rights standards. Survey, certification, and enforcement are governed by 42 C.F.R. Part 488.
• CMS enforcement remedies. CMS may impose civil money penalties (per-instance up to approximately $24,000 and per-day amounts within statutory ranges; verify current penalty bands at 42 C.F.R. § 488.408 and the annual inflation adjustment), denial of payment for new admissions, directed plans of correction, temporary management, and termination from federal payment. CMP funds returned to Wisconsin are reinvested through the DHS CMP Reinvestment Program.
• Wisconsin enforcement. Under § 50.04(4), DHS may impose remedies including forfeitures, plans of correction, suspension of admissions, and revocation or non-renewal of license. State court actions may also include injunctive relief under § 50.04(5)(c).
• Transfer / discharge protections. Permissible reasons for involuntary transfer/discharge are limited under 42 C.F.R. § 483.15(c) and Wis. Admin. Code DHS 132.53. The facility must provide thirty (30) days' written notice (with limited exceptions) and must inform the resident of appeal rights to the Wisconsin Division of Hearings and Appeals.
• Resident rights under Wis. Stat. § 50.09. State law specifies protections including private communications, sealed mail, telephone access, retention of personal effects, accountings of facility-managed funds, the right of married/partnered residents to share a room, and notice of room changes.
• Recording laws. Wisconsin is generally a one-party consent state for audio recording under Wis. Stat. § 968.31; however, hidden cameras in private rooms implicate roommate-privacy and DHS-132 dignity standards. Consult counsel before deploying surveillance.
• Concurrent APS reporting. Allegations of abuse, neglect, or financial exploitation must also be reported under § 46.90 (statewide hotline 1-833-586-0107) and may be referred for criminal prosecution under § 940.285 and § 940.295.
• Civil claims. Conduct described herein may give rise to civil actions for negligence, medical malpractice (under Wis. Stat. ch. 655 if applicable), violation of resident rights under § 50.09(6) (private right of action with statutory remedies and attorney fees), or claims under federal nursing home standards. The three-year statute of limitations under § 893.54 generally applies to personal-injury claims.
• Family Care / IRIS residents under age 60. Disability Rights Wisconsin operates the Family Care & IRIS Ombudsman Program for participants under age 60; contact 1-800-928-8778.

14. SOURCES AND REFERENCES

• Wisconsin DHS — Filing Complaints (Consumer Guide) — https://www.dhs.wisconsin.gov/guide/complaints.htm
• Wisconsin DHS Division of Quality Assurance — https://www.dhs.wisconsin.gov/dqa/index.htm
• Wisconsin Long-Term Care Ombudsman (Board on Aging and LTC) — https://longtermcare.wi.gov/Pages/Ombudsman.aspx
• Wisconsin Aging — Long-Term Care Ombudsman — https://www.dhs.wisconsin.gov/aging/ltcombud.htm
• Disability Rights Wisconsin — Family Care and IRIS Ombudsman Program — https://disabilityrightswi.org/program/family-care-and-iris-ombudsman-program/
• Wis. Stat. ch. 50 — https://docs.legis.wisconsin.gov/statutes/statutes/50
• Wis. Stat. § 50.09 — https://docs.legis.wisconsin.gov/statutes/statutes/50/09
• Wis. Admin. Code DHS 132 (Nursing Homes) — https://docs.legis.wisconsin.gov/code/admin_code/dhs/110/132
• 42 C.F.R. Part 483 (Long Term Care Facilities) — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• 42 C.F.R. Part 488 (Survey, Certification, Enforcement) — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-488
• CMS Civil Money Penalty Reinvestment Program — https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/civil-money-penalty-reinvestment-program
• Wisconsin Elder Abuse Hotline (1-833-586-0107) — https://gwaar.org/elder-abuse-hotline
• Nursing Home Reform Act overview — https://www.nursinghomelawcenter.org/news/nursing-home-reform-act-obra/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. A Wisconsin-licensed attorney must review and customize this document before use, particularly for matters involving abuse, retaliation, improper discharge, or potential civil litigation. Verify all hotline numbers, statutory citations, and federal enforcement procedures before submission.