Nursing Home Complaint Form

Instructions

The New York State Department of Health, Division of Residential Services, reviews complaints related to resident care and services that are provided in a Nursing Home which directly or indirectly affected the resident. To file a complaint about services provided, please complete this form.

Complaints will be accepted if the occurrence is within the past year of the submission of your complaint to the NYS Department of Health.

In order to process your complaint in a timely manner, please:

The Department of Health has authority from the Centers for Medicare and Medicaid to investigate Nursing Home complaints and occurrences which have, or may result in a negative outcome to residents. It is the role of DOH to ensure that facilities are in compliance with regulatory requirements, and to investigate occurrences of abuse, neglect or mistreatment.

The most common types of complaints include: accidents, changes in medical condition that were not addressed in a timely manner, admission and discharge issues, and housekeeping and maintenance issues.

Professional staff will review your concerns and determine how the department will proceed.

Should you have questions, please contact the Centralized Complaint Intake Program at 1-888-201-4563, Monday through Friday 8:30am- 4:45 pm, excluding holidays.

Nursing Home Complaint Form

Contact Information

Providing information about you will allow Department staff to contact you should additional information be needed. It is our policy to keep your name confidential. It may be necessary to share the nature of your complaint or the resident's name or your name with the facility.

Do you wish to remain anonymous? (See above explanation)
Please provide your contact information for the Department
May we leave a message?
May we leave a message?
Resident Information
Current location
Facility Information
Complaint Information
Is law enforcement involved?
Was the care plan followed?
Has resident abuse/neglect occurred?
Have you filed a complaint with the facility?
Was your concern resolved?
To whom have you spoken?
When did your concern occur?
Is the problem ongoing?
Are other residents affected by your concern?
Submit Your Complaint