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Nursing Home Abuse Complaint Form

This form should be used as a guide for what to include when filing a nursing home abuse complaint.

Date Completed
_____________
Name of person filing complaint
________________________________
Address
________________________________
City___________
State__________
Zip____________

Daytime phone number_____________
Evening phone number_____________
Name of facility_____________________________________________
Address of facility____________________________________________
City____________
State___________
Zip_____________

Name of resident on whose behalf the complaint is made:

Complaint:



Date(s) of incident:

Shift(s) when incident(s) occurred: Day/Afternoon/Night

Time(s):

Witnesses to Event:

Records to be examined:

Name of staff person(s) involved:

Mark off the following statements if they are applicable to your situation.

__ I have sent a copy of my complaint to the appropriate Licensing and Certification district office of the California Department of Health Services.

__ I am sending an additional copy to CANHR/APE/AoA (or other applicable resident advocate organization).

__ I wish to know the name of the investigator assigned to this complaint.

__ I wish to speak with the investigator before they make their onsite visit to investigate the claim.

__ I wish to accompany the investigator to the facility when the complaint investigation is being done.

__ I wish to remain anonymous. I do not want my name or identity known to the nursing facility.

__ I would like a copy of the final complaint report, and notice of my rights if I am not satisfied with your findings.

 

If the safety and health of your loved one is in jeopardy, and you feel that they have suffered some form of nursing home abuse or neglect, contact us to speak with an attorney.


HOMEPAGE - NURSING HOME ABUSE NEWS

AN OVERVIEW OF NURSING HOME ABUSE

INSTITUTIONAL ELDER ABUSE

GOVERNMENT ACTION AGAINST ELDER ABUSE

FILING A COMPLAINT

PROTECTING YOUR ELDER AGAINST NURSING HOME ABUSE

RESIDENT RIGHTS

SAMPLE NURSING HOME ABUSE COMPLAINT FORM

NURSING HOME ABUSE FAQs

LINKS

CONTACT A NURSING HOME ABUSE ATTORNEY

SITE MAP

Resident Rights

Visitation

Equal Access

Grievances

Married Couples

Rights and Services

Protection of Funds

Privacy

Staff Treatment

 

Links

Nursing Home Abuse in the News

Organizations to Assist in Elder Abuse Cases

Information on Rules, Nursing Homes, etc.


Community Based Sites

     
Nursing Home Abuse Complaint Form
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