When Should You File a Nursing Home Complaint?

 

In every state, there is a government agency that is responsible for conducting investigations into complaints against nursing homes for providing substandard care. But many patients and families often struggle with the question of whether they should indeed file a complaint to address the concerns they have encountered. Below we will discuss the right to file a complaint, how the filing of a complaint can be helpful, and finally under what circumstances you may want to consider filing a complaint.

Your Right to File a Complaint Against a Nursing Home

Unfortunately, nursing home abuse and neglect is all too common. One remedy to help combat the epidemic of substandard care in U.S. nursing homes is the right to file a complaint with the state’s regulatory body. Anyone with knowledge or concerns about the care of a nursing home patient has the right to file a complaint with their state’s regulatory agency, including the patient herself/himself, family members, guardians or other patient representatives, persons who are simply visiting the nursing home, and even the nursing home facility staff. Complaints can be filed anonymously and the complainant’s name and any specific medical information is confidential.

Why Filing a Nursing Home Complaint Can be Helpful

Filing a complaint with your state regulatory agency is an important step in the process towards accountability. Although there is no direct monetary compensation available from filing the complaint and the penalties to nursing homes are typically relatively minor, a complaint on file allows for more oversight by state authorities. It gives state investigators the ability to enter the facility without notice, pull and review records, interview staff, address the issues of concern, and preserve important evidence for potential future proceedings.

An investigation into the complaint by the State achieves a variety of things. First and foremost, a State investigator can help put an immediate stop to an ongoing problem that’s either harming a patient or has the capacity to harm a patient. In doing so, the investigator’s actions can also help prevent similar harm to other patients. If the investigator finds evidence to substantiate the complaint, then they will issue a Plan of Correction, which is designed to correct the failures of the nursing home. By filing your complaint, you have quite possibly intervened and effectuated changes at the facility that may not only prevent further harm to your loved one, but also help protect the facility’s other patients.

Second, a complaint will hold nursing homes financially accountable for their wrongdoings. All nursing homes that accept Medicare and/or Medicaid dollars promise that, in return for receiving these taxpayer funds, they will render care in a manner that ensures that patients’ needs are met. By filing a complaint to alert State investigators of substandard care, you’re helping to hold bad nursing homes accountable so that they’re either forced to improve practices or face the prospect of losing their most significant revenue streams — Medicare and Medicaid.

Third, filing a complaint that results in a Plan of Correction being issued requires that the report stating the nursing homes’ deficiencies be made public record. This report will be available online at the Nursing Home Compare website and, in many instances, other State nursing home sites. These public reports allow for other families to make the best decision for their loved ones when choosing a nursing home.

Lastly, filing a complaint with your State ensures that the investigation will generate and preserve evidence that may be required to successfully pursue a criminal action or civil lawsuit against the nursing home should actions become necessary. Importantly, these reports can be used to establish that those responsible for the nursing home were put on notice of substandard care issues within the facility, had a duty to correct the problems, and despite promises to correct them (the Plan of Correction), ignored them and continued to conduct business as usual, which ultimately led to further neglect, abuse, and harm.

When Should You Consider Filing a Complaint?

It is not necessary to know exactly which regulation or law is being violated by the nursing home in question; If you have a concern about the care provided – file a complaint.
While there’s no formal, comprehensive checklist for each and every issue that one could possibly be concerned about, following are some examples of issues that are often the subject of complaints against, and citations of, nursing homes providing substandard care:

Accommodation of Needs

• Did the nursing home deny a patient reasonable accommodations of individual needs and preferences?[1] The facility should attempt to adapt schedules, call systems, staff assignments and room arrangements to accommodate patient preferences, desires and unique needs.[2]For example, if a patient refuses a bath because he or she prefers a shower, prefers bathing at a different time of day or on a different day, does not feel well that day, is uncomfortable with the aide assigned to help, or is worried about falling, the staff should acknowledge that the patient is not refusing to be clean, but refusing the bath under the circumstances and make the necessary adjustments.[3]
• Did the facility manage language or communication barriers between patients and staff? The facility is required to use interpreters or other measures to ensure adequate communication.[4]

Adequate Staff

  • Did the nursing home fail to have sufficient staff to meet the needs of each patient in the nursing home at all times?[5] The facility must have on hand an adequate number of licensed nursing and certified nursing assistants. Some states require a minimum number of hours of nursing care per patient day. The facility must post daily, for each shift, the current number of licensed and unlicensed nursing staff directly responsible for patient care.
    Signs to look for:

    • Are call lights not answered in a timely manner?
    • Are patients with mobility problems not being turned and repositioned at least every two hours while in bed, and at least once per hour while in a wheelchair?
      Does the staff complain that the facility is understaffed?
    • Are patients getting the assistance they need to eat meals?
    • Do you have trouble finding a staff member when a patient needs assistance?
    • Do staff respond to bed and chair alarms quickly enough to prevent patients from falling?

Care Planning

• Did the facility fail to establish a comprehensive, individualized care plan for the patient?[6] The care plan should detail the patient’s specific care needs and how they will be met.

Continence & Toileting Help

Did the nursing facility staff:
• fail to ensure that a patient with bladder or bowel control problems was promptly assessed and effectively treated to improve the condition?[7] Incontinence and inadequate toileting assistance can cause many serious problems, including discomfort, skin rashes, pressure sores, falls, sense of isolation and psychological harm.
• use catheters without valid medical justification?[8] Nursing homes are not allowed to use a catheter for the convenience of staff or to compensate for not hiring sufficient staff to ensure that patients receive toiling assistance when they need it. Catheters cause discomfort, limit mobility and increase the risk of infection, bladder stones and cancer.[9] For catheter users, facilities must act to prevent urinary tract infections and restore as much normal bladder function as possible.
• fail to provide toileting assistance for a patient who needs it? Many nursing home patients need help with toileting, even if they’re not incontinent (e.g., a patient who has limited mobility; or a patient with dementia who may need reminders. Nursing homes must help these patients use the toilet as often as needed.[10]

Feeding Tubes

Did the nursing facility staff:
• use a feeding tube for its own convenience rather than as a last resort? Feeding tubes can cause serious medical and psychological problems and lead to a loss of functioning, thus no tube should ever be used for a patient who can swallow and receive adequate nutrition orally, no matter how long it takes to feed the patient.[11] Lack of staff is no excuse.[12] A feeding tube can be used with the patient’s consent when there’s a demonstrated medical need to prevent malnutrition or dehydration. But even then, all possible alternatives should be explored first.[13]
• fail to provide a patient fed by tube with the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, and other adverse symptoms?[14]
• fail to do all it could to help a patient with a feeding tube take food by mouth again as soon as possible?[15]

Food and Nutrition

  • Did the nursing facility staff fail to provide a patient a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs?[16] Nursing homes are required to:
    • Serve at least three meals daily, at regular times, with no more than a 14-hour span between the evening meal and breakfast;[17]
    • Offer snacks at bedtime;[18]
    • Reasonably accommodate patient food and mealtime preferences;[19]
    • Offer a food substitute of similar nutritional value if a patient refuses food;[20]
    • Serve food attractively, at the proper temperature, and in a form to meet individual needs;[21]
    • Prepare and follow menus that meet national dietary standards;[22]
  • Did the nursing home fail to:
    • ensure that a patient’s ability to eat was not diminished unless it was medically unavoidable?[23]
    • provide individualized help to a patient who needs meal assistance, including enough time to enable the patient to finish meals?[24]
    • provide special eating utensils to a patient who needs them?[25]
    • provide table service (at a table of appropriate height) to a patient who desired it?[26]
    • store, prepare, distribute or serve food under sanitary conditions?[27]
    • establish an individualized care plan to maintain the patient’s ability to eat food orally if the patient’s ability to eat is compromised?[28]
    • notify a patient’s physician immediately of signs of malnutrition (e.g., weight loss of 5 lbs. or more within a 30-day period)?[29] Federal guidelines urge nursing homes to reassess nutritional status whenever a patient experiences unplanned or undesired weight loss of 5% or more in one month, 7.5% or more in three months, or 10% or more in 6 months.[30]

Infection Control

Nursing homes are required to have an organized infection control program that prevents diseases and infections from developing and spreading.[31]

Did the nursing home fail to:

• ensure that staff members wash their hands after each direct contact with a patient?
• prohibit staff who have communicable diseases or infected skin conditions from having direct contact with patients or their food?
• clean and disinfect contaminated articles and surfaces?

Medications

Did the nursing home staff:

• fail to ensure the patient and his/her legal representative’s right to consent to or to refuse any treatment, including use of medications?[32]
• fail to ensure that the patient’s medication was prescribed (whether routine, emergency, or on as-needed basis) in a timely manner? (This requirement is not met if late administration of a prescribed drug causes the patient discomfort or endangers his or her health and safety.[33]) Doses must be administered within 1 hour of the prescribed time unless otherwise indicated by the prescriber.[34] Nursing homes are required to have 24–hour arrangements with one or more pharmacies.[35]
• overprescribe or allow the patient to use any unnecessary drugs? An unnecessary drug is any drug given: (1) in excessive dose; (2) for an excessive period of time; (3) without adequate monitoring; (4) without adequate justification; or (5) in the presence of adverse consequences that indicate the dose should be reduced or discontinued.[36]
• allow for the use of restricted drugs (such as sedatives, tranquilizers and similar drugs) when the medical need was not clearly documented?[37] Federal guidelines discourage nursing homes from using drugs with a high potential for severe adverse outcomes in older individual.[38]
• administer an antipsychotic drug to a patient without making sure it was necessary to treat a mental illness that has been diagnosed and documented in the resident’s clinical record?[39]
• fail to attempt discontinuation of antipsychotic drugs by substituting behavioral interventions and gradual dose reductions, unless clinically contraindicated?[40]
• allow for the use of drugs to treat behavioral symptoms? Except in emergencies, it is generally illegal to chemically restrain a patient; i.e., control a patient’s behavior through drugs when other forms of care and treatment would be more appropriate.[41]
• sedate the patient to cover up behavioral symptoms caused by any of the following: (1) environmental conditions such as excessive heat, noise, overcrowding; (2) psychosocial problems such as abuse, taunting, or ignoring a patient’s regular routine; or (3) treatable medical conditions such as heart disease or diabetes?[42]
• allow medications to be administered by someone other than licensed nurses or medical personnel?[43] Unlicensed staff may administer certain laxatives, non-prescription lotions, medicinal shampoos and baths, subject to specific training, demonstrated competence and direct supervision by licensed nursing or medical personnel.[44]
• fail to ensure that the person who administered the drug or treatment recorded the date, time, and dosage in the patient’s individual medication record?[45]
• fail to prevent a significant medication error? Nursing homes must keep medication error rates under 5% and ensure that patients are free of any significant medication errors.[46] A medication error is a discrepancy between the facility’s actions and either physician’s orders, manufacturer’s specifications, or accepted professional standards.[47] A medication error is considered “significant” when it causes the resident discomfort or jeopardizes his or her health and safety.[48]
• allow “medication sharing,” or give a medication to someone other than the patient for whom it was prescribed?[49]
• fail to obtain services from a licensed pharmacist to assess its medication system and to review the drug regimen of each resident on a monthly basis?[50] The pharmacist is required to report any irregularities to the patient’s attending physician, the administrator and director of nursing, who must act on the reports.[51]

Personal Care

Did the nursing home fail to:

• provide care to maintain clean, dry skin on the patient?[52]
• change soiled linens, clothing and other items to keep a patient’s skin is free from urine and feces?[53]
• provide needed personal care services including bathing, shampooing and grooming of hair, oral hygiene, shaving or beard trimming, and cleaning and cutting of fingernails and toenails?[54]
• ensure that patients are free of offensive odors?[55]
• answer call signals for personal care promptly?[56]
• ensure privacy during treatments and personal care?[57]

Physician Services

Did the nursing home fail to:

  • ensure that the patient’s care was supervised by a physician chosen by the patient or the patient’s representative?[58] Nursing homes may not place obstacles in the way of patients choosing their own physicians. For example, if a patient does not have a physician, or if the patient’s physician becomes unable or unwilling to continue treating the patient, the facility must help the patient exercise his/her choice in finding another physician.[59]
  • ensure that the patient was seen and evaluated by a physician at least every 30 days, or more often if needed?[60]
  • ensure that the physician had face-to-face contact with patients and reviewed the patient’s total program of care during required visits?[61] “Total program of care” means all care the facility provides, including medical services, medication management, therapy, nursing care, nutritional interventions, social work and activity services.[62]
  • ensure that a patient’s attending physician:[63]
    • Participated in the patient’s assessment and care planning?
    • Monitored changes in the patient’s medical status?
    •  Reviewed the patient’s total program of care at each required visit?
    • Prescribed new therapy and treatments as needed?
    • Ordered a patient’s transfer to the hospital?
    • Supervised nurse practitioners or physician assistants when follow-up visits were delegated to them?
    • Provided consultation or treatment when contacted by the facility?
    • Recorded the patient’s progress and problems in maintaining or improving their health status?
  • carry out doctors’ orders and arrange all necessary diagnostic and therapeutic services recommended by the patient’s physician, podiatrist, dentist or clinical psychologist?[64]
  • help the patient arrange transportation to and from a service location if the patient needed services that cannot be brought into the facility?[65]
  • notify the patient’s attending physician promptly of significant changes, such as:[66]

(1) a sudden or marked adverse change in signs, symptoms or behavior;
(2) an unusual occurrence involving the patient;
(3) a change in weight of five pounds or more within a 30-day period;
(4) an untoward response to a medication or treatment;
(5) a life threatening medication or treatment error; or
(6) a threat to the patient’s health or safety caused by the facility’s inability to obtain or administer prescribed drugs, equipment, supplies or services in a timely fashion.

• ensure that substitute doctors were available to provide supervision and emergency medical care whenever the patient’s physicians were unavailable?[67]

Pressure Sores

Patients who lie or sit in one position for long periods are at risk of developing pressure sores,(also known as bedsores or decubitus ulcers), which occur when pressure on the skin shuts off blood vessels, depriving skin tissue of oxygen and nutrients. If proper care is not given, large, deep sores can develop, sometimes exposing the muscle or bone beneath the skin. Untreated pressure sores can lead to infection, severe pain and death. Generally, pressure sores can be prevented with proper care.[68]

Did the nursing home staff:

  • let a patient who is bed-bound and cannot reposition himself/herself lie in the same position for more than 2 hours?
  • let a patient in a wheelchair who cannot reposition himself/herself sit without being repositioned for more than 1 hour?
  • allow a patient who entered the facility without a pressure sore to develop a pressure sore?
  • allow a patient with a pressure sore to go without treatment to promote healing and prevent infection?[69]
  • fail to keep a resident’s skin clean and dry?
  • fail to consistently use pressure relieving devices, such as pads and special mattresses?[70]
  • fail to ensure that a bed-bound patient had his/her heels elevated off the mattress?
  • fail to notify the patient’s family and physician when a pressure sore first developed?
  • fail to relieve pressure from a pressure sore, once it developed, in order to allow the wound to heal?
  • fail to ensure that a patient received proper nutrition and hydration necessary for healthy skin?
  • fail to promptly notify the resident’s physician if a pressure sore treatment order was not effective?[71]

Preventing Accidents

Falls and accidents are a serious concern for nursing home patients and facilities have a responsibility to take measures to prevent them. Approximately 50% of nursing home patients fall annually, and 10% of these falls cause serious injury, especially hip fractures.[72]

Did the nursing home fail to:

  • identify a patient as a fall risk and develop a plan of care with interventions to help keep him/her safe? If a patient has fallen, been injured, or is considered at risk for falling, his/her care plan must individually address this concern and identify steps to be taken to improve safety.
  • keep a patient’s environment as free of accident hazards as possible (e.g., tripping hazards, slick floors, cords and tubing, etc.)?
  • provide a patient with adequate supervision to prevent accidents?
  • provide adequate assistive devices to help improve resident safety?[73]
  • provide adequate lighting?
  • provide sufficient staff to safely assist the patient with transfers?
  • use a gait belt to safely assist a patient when one was needed?
  • ensure that bed rails were in their proper position?
  • answer call lights when patients needed assistance getting up?
  • provide sufficient staff to respond to personal alarms in a timely fashion?
  • provide bedside mats for a patient at risk of falling from his/her bed?
  • ensure that the bed was in a lowered position for a patient who is at risk of falling out of bed?
  • take into account the patient’s personal risk factors in assessing their fall risk?
  • lock a patient’s wheelchair wheels when they were supposed to?

Special Services

Did the nursing home fail to ensure that a patient received proper treatment and care for:[74]

  • injections?
  • IV fluids?
  • a colostomy?
  • a ureterostomy?
  • an ileostomy?
  • a tracheostomy?
  • tracheal suctioning?
  • respiratory care?
  • foot care?
  • a prostheses?

Federal law requires that these services be provided if a patient needs them, regardless of whether they’re covered by Medicare or Medicaid.[75] For services not covered, a nursing home is required to assist the patient in securing any available resources to obtain the needed services.

Therapy Services (Therapies, Restorative Care and Range of Motion)

Nursing home patients often need specialized rehabilitative services to restore lost abilities caused by strokes, broken bones or other conditions. The nursing home must provide needed therapy services, no matter who’s paying for the nursing home stay.[76]

Did the nursing home staff:

  • fail to ensure that a patient received the therapy needed to reach his/her highest practicable level of functioning?[77] (Includes therapy services such as, but not limited to, physical therapy, occupational therapy, speech–language pathology and mental health rehabilitative services.[78])
  • improperly shortened therapy by claiming that a patient is not improving or has plateaued? Medicare rules say that improvement is not necessary. Therapy services can be covered if they’re needed to prevent further deterioration or preserve current capabilities.[79]
  • illegally halt formal therapy services when a patient exhausted Medicare skilled nursing facility coverage? Specialized rehabilitative services are a covered Medicaid service and must be provided to patients who need them without charge.[80]
  • fail to ensure that, as formal therapy services were ending, the therapist established a care plan that continues needed exercises and other services with the help of facility nursing staff (“restorative care”)? For example, a patient recovering from a fractured hip may need assistance with daily walking, which should continue as long as needed without any extra fee if Medicare is paying for the patient’s nursing home care.
  • fail to ensure routine care for “range of motion exercises” with the hands, arms, legs and feet so the patient didn’t lose joint mobility or develop contractures (freezing of the joint in a contracted position), unless it was medically unavoidable? Did the facility offer appropriate treatment and services if the patient has limited range of motion?[81] Preventive care may include exercise of the joints performed by the patient, with or without assistance by staff. Range of motion exercises, however, should never be used as a substitute for patients who need specialized therapies from licensed therapists.

Vision, Dental and Hearing Care

Did the nursing home fail to:

  • ensure that a patient’s care plan comprehensively addressed his/her dental, vision and hearing services needs?
  • assist a patient obtain routine (annual exam) and emergency dental care?[82] An “emergency” involves pain or other dental problem that requires immediate attention.[83]
  • make a prompt referral to a dentist and to aggressively work at replacing lost or damaged dentures?[84]
  • arrange treatment to maintain a patient’s ability to see or hear?[85]
  • make necessary appointments and arrange transportation for services received away from the facility for a patient who needed hearing or vision care or assistive devices?[86] Assistive devices includes glasses, contact lenses, magnifying glasses and hearing aids.[87]
  • help the patient and family locate and utilize any available community resources or payment programs, including Medicare and Medicaid?[88]

How To File A Nursing Home Complaint

You may file the complaint by various means, including emailing, mailing, calling, or faxing the appropriate state agency. Some states even provide their own complaint forms. A list of all States and their survey agencies is available here: https://www.medicare.gov/NursingHomeCompare/Resources/State-Websites.html.

Conclusion

Abuse, neglect, and substandard care has no place in a nursing home. Nursing homes that fail to uphold their responsibility to provide proper care need to be held accountable. One of the best ways to hold a bad nursing home accountable is to file a complaint with the state regulatory body that oversees nursing homes. An investigation can help stop the problem, publicize the problem so other patients and families can take note, and ultimately help ensure that the nursing home is held accountable. If properly held accountable, nursing homes will be less likely to allow for neglect, abuse and substandard care within their facility.

REFERENCES

[1] 42 CFR 483.15(e).
[2] Surveyor’s Guideline to 42 CFR §483.15(e), Appendix PP to CMS State Operation Manual.
[3] (Title 22 CCR §72501(f), see also 42 CFR 483.10(b)(1).
[4] Title 22 CCR §72501(f), see also 42 CFR 483.10(b)(1).
[5] 42 CFR §483.30, California Health & Safety Code §1599.1(a), Title 22 CCR §§72329(a) & 72501(e).
[6] 42 CFR §483.20
[7] 42 CFR §483.25(d)(2), Title 22 CCR §72315(i).
[8] 42 CFR §483.25(d)(1).
[9] CMS’ Patient Assessment Instrument Version 2.0 Manual, Appendix C, §6 (Urinary Incontinence & Indwelling Catheter), Page C–30, revised December 2002.
[10] 42 CFR §483.25(a)(1).
[11] 42 CFR §483.25(g)(1).
[12] CMS’ Resident Assessment Instrument Version 2.0 Manual, Appendix C, §13 (Feeding Tubes), Page C–68, revised December 2002.
[13] CMS’ Resident Assessment Instrument Version 2.0 Manual, Appendix C, §13 Feeding Tubes), Page C–68, revised December 2002.
[14] 42 CFR §483.25(g)(2).
[15] 42 CFR §483.25(g).
[16] Title 22 CCR §72335, 42 CFR §483.35.
[17] Title 22 CCR §72335(a)(1), 42 CFR §483.35(f).
[18] Title 22 CCR §72335(a)(2), 42 CFR §483.35(f).
[19] Title 22 CCR §72335(a)(3), 42 USC §1396r(c)(1)(A)(v), 42 CFR §483.15(b)(1).
[20] Title 22 CCR §72335(a)(3), 42 CFR §483.35(d)(4).
[21] Title 22 CCR §72335(a)(7), 42 CFR §483.35(d).
[22] Title 22 CCR §72341, 42 CFR §483.35(c).
[23] 42 CFR §483.25(a)(1)(iv).
[24] 42 CFR §483.25(a)(1)–(3), Title 22 CCR §72315(g).
[25] 42 CFR §483.35(g), Title 22 CCR §72335(a)(7), Title 22 CCR §72315(g).
[26] Title 22 CCR §72335(a)(4).
[27] 42 CFR §483.35(h), Title 22 CCR §72343 – 72349.
[28] Title 22 CCR §72315(g), CMS’ Resident Assessment Instrument Version 2.0 Manual, Appendix C, §12 (Nutritional Status), Page C–63, revised December 2002.
[29] Title 22 CCR §72311(a)(3)(D).
[30] Surveyor’s Guideline to 42 CFR §483.25(i), Appendix PP to CMS State Operation Manual.
[31] 42 CFR §483.65, Title 22 CCR §72321–72323.
[32] Title 22 CCR §72527(a)(4), 42 CFR §483.10(b)(4).
[33] 42 CFR §483.60, Surveyor’s Guideline to 42 CFR §483.60, Appendix PP to CMS State Operation Manual, See also Title 22 CCR §72355.
[34] Title 22 CCR §72313(a)(6).
[35] Title 22 CCR §§72353 – 72355, 42 CFR §483.60.
[36] 42 CFR §483.25(l).
[37] Surveyor’s Guideline to 42 CFR §483.25(l), Appendix PP to CMS State Operation Manual.
[38] Surveyor’s Guideline to 42 CFR §483.25(l), Appendix PP to CMS State Operation Manual.
[39] 42 CFR §483.25(l)(2)(i).
[40] 42 CFR §483.25(l)(2)(ii).
[41] 42 USC §1396r(c)(1)(A)(ii), 42 CFR §483.13(a), Title 22 CCR §72527(a)23).
[42] Surveyor’s Guideline to 42 CFR §483.25(l), Appendix PP to CMS State Operation Manual.
[43] Title 22 CCR §72313(a)(5).
[44] Title 22 CCR §72313(a)(5)(B).
[45] Title 22 CCR §72313(c).
[46] 42 CFR §483.25(m).
[47] Surveyor’s Guideline to 42 CFR §483.25(m), Appendix PP to CMS State Operation Manual.
[48] Surveyor’s Guideline to 42 CFR §483.25(m), Appendix PP to CMS State Operation Manual.
[49] Title 22 CCR §72313(b).
[50] 42 CFR §483.60(b)&(c), Title 22 CCR §72375.
[51] 42 CFR §483.60(c)(2), Title 22 CCR §72375.
[52] Title 22 CCR §72315(f)(5).
[53] Title 22 CCR §72315(f)(6).
[54] Title 22 CCR §72315(d).
[55] Title 22 CCR §72315(d).
[56] Title 22 CCR §72315(m)
[57] Title 22 CCR §72315(l).
[58] 42 CFR §483.40, 42 CFR §483.10(d)(1), Title 22 CCR §72303 & 72307.
[59] Surveyor’s Guideline to 42 CFR §483.10(d)(1), Appendix PP to CMS State Operation Manual.
[60] 42 CFR §483.40(c), Title 22 CCR §72307.
[61] 42 CFR §483.40, Surveyor’s Guideline to 42 CFR §483.40, Appendix PP to CMS State Operation Manual.
[62] 42 CFR §483.40, Surveyor’s Guideline to 42 CFR §483.40, Appendix PP to CMS State Operation Manual.
[63] Surveyor’s Guideline to 42 CFR §483.40, Appendix PP to CMS State Operation Manual.
[64] Title 22 CCR §72301(d)&(f).
[65] Title 22 CCR §72301(d).
[66] Title 22 CCR §72311(a)(3).
[67] 42 CFR §483.40, Title 22 CCR §72301(g).
[68] CMS’ Resident Assessment Instrument Version 2.0 Manual, Appendix C, §16 (Pressure Ulcers), Page C–84, revised December 2002.
[69] 42 CFR §483.25(c).
[70] Title 22 CCR §72315(f).
[71] Title 22 CCR §72315(f)(7).
[72] CMS’ Resident Assessment Instrument Version 2.0 Manual, Appendix C, §11 (Falls), Page C–59, revised December 2002.
[73] 42 CFR §483.25(h).
[74] 42 CFR §483.25(k).
[75] Surveyor’s Guideline to 42 CFR §483.25(k), Appendix PP to CMS State Operation Manual.
[76] 42 USC §1396r(c)(4)(A).
[77] 42 USC §1395r(b)(4)(A)(i).
[78] 42 CFR §483.45(a).
[79] 42 CFR §409.32.
[80] Surveyor’s Guideline to 42 CFR §483.45(a), Appendix PP to CMS State Operation Manual.
[81] 42 CFR §483.25(e).
[82] 42 CFR §483.55.
[83] Surveyor’s Guideline to 42 CFR §483.55, Appendix PP to CMS State Operation Manual.
[84] 42 CFR §483.55, Surveyor’s Guideline to 42 CFR §483.55, Appendix PP to CMS State Operation Manual.
[85] 42 CFR §483.25(b).
[86] 42 CFR §483.25(b), Surveyor’s Guideline to 42 CFR §483.25(b), Appendix PP to CMS State Operation Manual.
[87] Surveyor’s Guideline to 42 CFR §483.25(b), Appendix PP to CMS State Operation Manual.
[88] Surveyor’s Guideline to 42 CFR §483.25(b), Appendix PP to CMS State Operation Manual.

 Jeff Powless is an attorney and the author of the 2017 book, Abuses and Excuses: How To Hold Bad Nursing Homes Accountable.  Abuses and Excuses breaks new ground in helping patients and families hold bad nursing homes accountable, sharing a wealth of insider strategies and insights. It’s an eye-opening account of corporate greed, acts of neglect and abuse, an insidious industry culture of cover-up, and the actual harm that inevitably befalls vulnerable nursing home patients all across the country with shocking frequency.

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