Wyoming Nursing Home Resident Complaint — Long-Term Care Ombudsman / DOH Healthcare Licensing & Surveys

WYOMING NURSING HOME RESIDENT COMPLAINT

TABLE OF CONTENTS

1. Filing Channels and Routing
2. Complainant Information
3. Resident Information and Authorization
4. Facility Information
5. Statement of Resident Rights Implicated
6. Statement of Complaint
7. Specific Incidents — Chronological Detail
8. Internal Grievance Process Exhausted
9. Witnesses and Documentary Evidence
10. Requested Relief
11. Cross-Reporting and Parallel Filings
12. Complainant Certification
13. Wyoming Practice Notes
14. Sources and References

1. FILING CHANNELS AND ROUTING

This complaint is being submitted to (check all that apply):

• ☐ Wyoming Long-Term Care Ombudsman Program (advocacy / resolution)
• Wyoming Senior Citizens, Inc., 1-800-856-4398
• State Long-Term Care Ombudsman, Wyoming Department of Health, 2300 Capitol Avenue, Hathaway Building, 4th Floor, Cheyenne, WY 82002 — 307-287-7757
• ☐ Wyoming Department of Health, Office of Healthcare Licensing & Surveys (state survey / enforcement)
• 307-777-7123 — 6101 Yellowstone Road, Suite 186C, Cheyenne, WY 82002
• ☐ Wyoming DFS Adult Protective Services (1-800-457-3659) — abuse / neglect / exploitation
• ☐ CMS Region VIII (Denver) — federal escalation for certified facility
• ☐ Wyoming Attorney General — Medicaid Fraud Control Unit — billing fraud or resident-fund theft
• ☐ Wyoming Board of Nursing / Board of Medicine — licensee misconduct
• ☐ Local law enforcement (sheriff / police) — criminal conduct

2. COMPLAINANT INFORMATION

3. RESIDENT INFORMATION AND AUTHORIZATION

4. FACILITY INFORMATION

5. STATEMENT OF RESIDENT RIGHTS IMPLICATED

Check each right reasonably implicated by the conduct described. Federal citations are to 42 C.F.R. § 483.10 (NHRA Resident Rights) and related provisions.

• ☐ Right to dignity and self-determination (§ 483.10(a))
• ☐ Right to be free from abuse, neglect, exploitation, misappropriation of property (§ 483.12)
• ☐ Right to be free from physical or chemical restraints not required to treat medical symptoms (§ 483.10(e); § 483.12(a)(2))
• ☐ Right to participate in care planning (§ 483.10(c))
• ☐ Right to refuse treatment / refuse transfer (§ 483.10(c)(6))
• ☐ Right to access personal medical records within 24 hours (§ 483.10(g)(2))
• ☐ Right to manage financial affairs / safeguarding of resident funds (§ 483.10(f)(10); § 483.10(c)(8))
• ☐ Right to privacy in treatment, communications, visitors (§ 483.10(h))
• ☐ Right to voice grievances without reprisal (§ 483.10(j))
• ☐ Right to notice of bed-hold / transfer / discharge with appeal rights (§ 483.15)
• ☐ Right to choose physician / pharmacy (§ 483.10(d))
• ☐ Right to immediate access by Ombudsman, family, physician, attorney (§ 483.10(f)(4))
• ☐ Right to participate in resident / family councils (§ 483.10(f)(5)–(6))
• ☐ Right to a safe, clean, comfortable, homelike environment (§ 483.90)
• ☐ Right to sufficient nursing staff (§ 483.35)
• ☐ Right to receive services of adequate quality (§ 483.25 — quality of care)
• ☐ Wyoming-specific right under DOH HLS Rules Ch. 4 (state-licensed facilities)

6. STATEMENT OF COMPLAINT

Concise summary (≤ 5 sentences) of the conduct complained of:

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

Category of complaint (check all that apply):

• ☐ Quality of care (pressure ulcers, falls, medication errors, untreated infection, weight loss, dehydration, hygiene)
• ☐ Abuse — physical / verbal / sexual / mental
• ☐ Neglect — failure to provide care, supervision, ADL assistance
• ☐ Misappropriation of resident funds or property
• ☐ Inappropriate use of restraints (physical or chemical)
• ☐ Improper transfer / involuntary discharge / eviction
• ☐ Bed-hold / readmission denial
• ☐ Failure to honor advance directive / POLST
• ☐ Retaliation against resident, family, or staff for raising concerns
• ☐ Staffing inadequacy
• ☐ Environmental / safety hazards (infection control, fire / life safety, sanitation)
• ☐ Dietary / nutrition deficiency
• ☐ Resident-on-resident altercation not adequately addressed
• ☐ Failure to provide notice or grievance access
• ☐ COVID-19 / infection-control violations
• ☐ Billing / Medicaid-Medicare fraud
• ☐ Other: [________________________________]

7. SPECIFIC INCIDENTS — CHRONOLOGICAL DETAIL

For each incident, provide objective fact-based detail. Add additional rows as needed.

Incident 1

Incident 2

Incident 3

8. INTERNAL GRIEVANCE PROCESS EXHAUSTED

42 C.F.R. § 483.10(j) requires every certified facility to maintain an internal grievance process and to designate a Grievance Official.

9. WITNESSES AND DOCUMENTARY EVIDENCE

Documentation enclosed or available:

• ☐ Photographs of injuries / room conditions (date-stamped)
• ☐ Resident medical records / MAR / care plan / nursing notes
• ☐ Facility incident reports
• ☐ Resident funds / trust-account ledgers
• ☐ Discharge / transfer notices
• ☐ Written grievances and facility responses
• ☐ Voicemails / texts / emails
• ☐ 911 / EMS / hospital ED records
• ☐ Coroner / autopsy report (if death occurred)
• ☐ Family meeting notes
• ☐ Other: [________________________________]

10. REQUESTED RELIEF

Check all that apply:

• ☐ Independent investigation by the Ombudsman or DOH HLS
• ☐ Onsite unannounced survey under 42 C.F.R. § 488.332
• ☐ Issuance of statement of deficiencies (CMS Form 2567)
• ☐ Plan of correction directed at the facility
• ☐ Civil monetary penalties / denial of payment for new admissions
• ☐ Decertification or license action where warranted
• ☐ Referral to law enforcement and / or APS
• ☐ Stay or rescission of pending discharge / transfer
• ☐ Restitution of misappropriated funds
• ☐ Care-plan revision and family meeting
• ☐ Restoration of bed-hold / readmission rights
• ☐ Mediation / advocacy through the Ombudsman
• ☐ Written response to complainant within 10 business days
• ☐ Other: [________________________________]

11. CROSS-REPORTING AND PARALLEL FILINGS

The complainant has also filed (or intends to file) reports with:

• ☐ Wyoming DFS Adult Protective Services (1-800-457-3659) — case no.: [____________]
• ☐ Local law enforcement — agency / report no.: [____________]
• ☐ CMS Region VIII (Denver Regional Office) — date filed: [__/__/____]
• ☐ Wyoming Board of Nursing — license action — date filed: [__/__/____]
• ☐ Wyoming Board of Medicine — date filed: [__/__/____]
• ☐ Wyoming Attorney General — Medicaid Fraud Control Unit — date filed: [__/__/____]
• ☐ Better Business Bureau / consumer-protection agency
• ☐ Civil counsel retained — firm: [____________]

12. COMPLAINANT CERTIFICATION

I certify that the foregoing is true and accurate to the best of my knowledge and belief. I make this report in good faith. I understand that the Wyoming Long-Term Care Ombudsman Program is independent of the facility and is required by federal law (42 U.S.C. § 3058g) to maintain confidentiality of resident-identifying information except as authorized by the resident or legal representative.

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

[COMPLAINANT — print and sign]

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

[RESIDENT or RESIDENT'S REPRESENTATIVE — consent to filing, if applicable]

13. WYOMING PRACTICE NOTES

• Two parallel tracks. The Ombudsman is an advocacy and resolution body — it does not issue citations or impose penalties. The DOH Office of Healthcare Licensing & Surveys is the state survey agency that conducts unannounced inspections, issues statements of deficiencies, and refers serious matters to CMS for federal enforcement.
• Wyoming Senior Citizens, Inc. (WSCI). WSCI contracts with DOH to operate the statewide Ombudsman Program. WSCI's hotline (1-800-856-4398) is the principal entry point for residents and family.
• HLS jurisdiction. HLS surveys nursing care facilities, assisted living, adult family-care homes, hospitals, ASCs, and home-health/hospice providers. Investigations of certified facilities follow CMS protocols (Appendix PP, State Operations Manual). DOH publishes complaint-investigation findings on the federal Care Compare site.
• Time limits and prioritization. CMS classifies complaints as Immediate Jeopardy (IJ — onsite within 2 working days), High (within 10 working days), Medium (within 45 days), or Low/Referred. State agencies are required to investigate within these federal timelines.
• Federal NHRA private right of action. The federal Nursing Home Reform Act does not itself create a private cause of action for damages. Civil claims arising from the conduct usually proceed under Wyoming common-law negligence, wrongful death (Wyo. Stat. § 1-38-101), survivorship, breach of contract, or violations of resident rights enforceable through state regulation.
• Statute of limitations — civil claims. Wyoming general personal-injury actions are subject to a four-year statute of limitations under Wyo. Stat. § 1-3-105(a)(iv)(C); medical-malpractice claims are subject to a two-year limit under Wyo. Stat. § 1-3-107 with a continuous-care exception. Wrongful-death actions must be filed within two years of the death (Wyo. Stat. § 1-38-102). Verify before filing.
• Pre-suit Medical Review Panel. Claims sounding in medical malpractice may, depending on the year and current statute, require pre-suit review through the Wyoming Medical Review Panel — confirm current status of Wyo. Stat. § 9-2-1513 before filing.
• Anti-retaliation. Federal regulations (§ 483.10(j)(4)) and Wyoming licensing rules prohibit retaliation against residents, families, or staff for filing a complaint. Document any post-complaint adverse action.
• Tribal facilities and IHS. Conduct on the Wind River Indian Reservation involving tribally operated or IHS facilities may implicate federal jurisdiction; coordinate with tribal social services and the BIA regional office.
• Criminal referral. Where conduct constitutes a crime under Wyo. Stat. § 6-2-507 (criminal abuse / neglect / exploitation of a vulnerable adult), parallel-refer to the county sheriff and prosecuting attorney.

14. SOURCES AND REFERENCES

• Wyoming Long-Term Care Ombudsman Program (DOH) — https://health.wyo.gov/admin/long-term-care-ombudsman-program/
• Wyoming Senior Citizens, Inc. — Long-Term Care Ombudsman — https://www.wyomingseniors.com/services/long-term-care-ombudsman
• Wyoming DOH Office of Healthcare Licensing & Surveys — Complaints — https://health.wyo.gov/aging/hls/complaints-against-healthcare-facilities/
• Wyoming DOH HLS — Consumer Information — https://health.wyo.gov/aging/hls/consumer-information/
• Wyoming DOH HLS — Rules and Regulations — https://health.wyo.gov/aging/hls/rules-and-regulations/
• Wyoming DOH HLS — Nursing Care Facility Information — https://health.wyo.gov/aging/hls/facility-types/nursing-care-facility-nursing-home-wyoming-licensure-information/
• Wyoming DFS — Adult Protective Services — https://dfs.wyo.gov/services/elderly-and-disabled/adult-protection-services/
• 42 U.S.C. § 1395i-3 (Medicare SNF requirements) — https://www.law.cornell.edu/uscode/text/42/1395i-3
• 42 U.S.C. § 1396r (Medicaid NF requirements) — https://www.law.cornell.edu/uscode/text/42/1396r
• 42 C.F.R. Part 483 — https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483
• 42 U.S.C. § 3058g (Long-Term Care Ombudsman Program) — https://www.law.cornell.edu/uscode/text/42/3058g
• CMS State Operations Manual, Appendix PP — https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS1201984
• CMS Care Compare (facility ratings, deficiencies) — https://www.medicare.gov/care-compare/
• Wyoming Statutes Title 35, Chapter 2 — https://law.justia.com/codes/wyoming/title-35/chapter-2/
• AARP Wyoming — Long-Term Ombudsman — https://states.aarp.org/wyoming/long-term-ombudsman-is-in-your-corner

Disclaimer: This template is informational and does not constitute legal advice. Laws, regulations, and contact information change. Verify current statutes, rules, and agency contacts before filing. Civil claims for personal injury, wrongful death, or other damages arising from the conduct described should be evaluated by a Wyoming-licensed attorney prior to expiration of the applicable statute of limitations.