File a Complaint

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File a Complaint

There are two individuals sitting and talking in a home atmosphere. The Ombudsman is an older white gentleman with salt and pepper hair, and he is seated and holding a large folder in a black face mask and a face shield. The resident is an older woman with short-cropped white hair pointing in the distance. She is dressed in a nice blue polo with a dark blue jacket.

Whether you live in a nursing home, a boarding home (“assisted living facility”), an adult family home, or a state operated veterans’ home, you or your advocate can pursue these options one at a time, simultaneously, and in any order:

Talk directly to facility staff
File a written grievance with the facility
Voice your concern and get support at a Resident Council meeting
Call your local LTC Ombudsman for advice and/or request their help and involvement (See the list of LTC Ombudsmen by County)
Call the DSHS Complaint Hotline (1-800-562-6078) and report your concern.
You will be asked to leave a message.
Provide specific details about your concern, your name and phone number, and a good time to reach you.
DSHS will call you back.
You also have the option to remain anonymous to the facility, DSHS, or to both entities.

Date of Actual Incident or Event:

Salutation:

Person Filing the Complaint:

First Last

In respect of your privacy, name is not required. A first name or preferred salutation is helpful for our staff in communicating with you.

Phone:(Required)

Email:(Required)

City:

Prefered Contact Time:

What is your relationship to the resident/patient?

Are you the:

Resident

Resident’s Legal Decision Maker (POA or DPOA legal guardian)

Family Member

Friend

Facility Employee

Other

Other (visitor, other provider, volunteer, Estate/Personal Representative)

Facility Name:

Facility Address

Street Address City State ZIP Code

If the address is unknown, the ZIP code or city is adequate.

Does the resident still reside in the facility named above?

Does the resident know that you are contacting the LTC Ombudsman for assistance?

Yes

Please explain the nature of your concern or complaint (in respect of the resident's privacy, please do not include full names in this form):

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