Care setting Nursing home or skilled nursing facility Assisted living or board-and-care home Memory care setting Not sure which setting applies
Concern stage Trying facility follow-up first Concern remains unresolved after staff follow-up Preparing or tracking a written grievance Possible urgent safety, neglect, abuse, or retaliation Planning ahead before a concern becomes urgent
Main concern Care quality, staffing, meals, hygiene, falls, or daily help Resident rights, dignity, privacy, choice, or visitors Discharge, transfer, eviction, or readmission concern Billing, personal funds, belongings, or missing property Communication, unanswered calls, or conflicting updates Abuse, neglect, exploitation, retaliation, or serious safety
Resident permission or participation Resident wants help or wants concern raised Need a private resident conversation first Representative, proxy, guardian, or agent involved Permission is unclear or resident cannot clearly say
Facility follow-up so far Not raised with facility yet Raised verbally, but no written answer Written response, grievance, or care-plan note exists No answer, delayed answer, or conflicting answers
Notes and records status No timeline or notes yet Some notes, but not organized Timeline and copies are organized privately
Urgency level Not urgent, but needs follow-up Needs monitoring over the next week Notice, discharge, appeal, or response deadline Same-day safety, medical, or rights concern
Fear of retaliation? No retaliation concern right now Not sure or resident seems hesitant Yes, retaliation or intimidation is a concern
Language or accessibility support needed? No extra support needed Interpreter, translation, hearing, vision, speech, or cognitive support needed
Next contact path Need to find local ombudsman contact Have local ombudsman contact May also need state agency, APS, plan, or legal aid
Use this to organize a long-term care concern before asking for help.
Use broad planning answers only. Do not enter names, room numbers, addresses, birth dates, diagnoses, medication names, Medicare or Medicaid numbers, account numbers, facility account numbers, photos, or detailed incident allegations.
This organizer is educational and organizational only. It is not legal, medical, regulatory, insurance, benefits, placement, or complaint advice. For immediate danger or urgent medical needs, contact emergency services, the care team, Adult Protective Services, the state survey or licensing agency, legal help, or another appropriate official resource directly.
Official references:
ACL Long-Term Care Ombudsman Program ,
Long-Term Care Ombudsman Resource Center ,
Medicare resident rights ,
CMS nursing home rights and quality care ,
Eldercare Locator .
