New Jersey Long-Term Care Ombudsman

Complaint Form

*NOTE: This LTCO Online Complaint Form is for consumer use only. Licensed Long-Term Care (LTC) facilities should NOT use this form. LTC facilities must use the AAS-45 "Reportable Event Record/Report" form located on our website and should FAX to the Ombudsman's Office at 609-943-3479.

Please note: The Office of the State Long Term Care Ombudsman is not a First Responder. In an Emergency, or if someone is in immediate danger, Please DIAL 911!

Please answer as many questions as possible. All information is confidential.

In order to submit this online complaint, you must provide your name in the form below. However, when we investigate your complaint, we will not use your name if you do not wish. If you want to file a complaint without providing your name, you can call our hotline 1-877-582-6995 and speak anonymously with an intake specialist.

This form can be used to report complaints pertaining only to the facility types listed below, which are under the jurisdiction of the LTCO.

Facility Type:

Full Name of Facility:

Street Address:

City:

State:

Zip:

Facility Telephone Number (if known): (Enter Numbers Only)

Do you wish to remain anonymous to the facility?

Name of Person Reporting:

Your E-mail Address:

Home Telephone Number: (Enter Numbers Only)

Work Telephone Number: (Enter Numbers Only)

Cell Phone Number: (Enter Numbers Only)

Are you willing to receive messages via text?

Relationship:

Enter Other Relationship Type:

Street Address of Person Reporting:

City:

State:

Zip:

Resident/Patient Name:

Room Number:

Date of Birth/Age:

Describe the event; be specific, include timeframes, staff/others involved.

Once your complaint is received, it will be reviewed by an intake supervisor. If the complaint is determined to be under the jurisdiction
of the LTCO, it will be assigned to an investigator/advocate. If you have provided a phone number, you may receive a call from the investigator/advocate seeking additional information before an unannounced visit is made to the facility to investigate your complaint.

Complaints for the NJ Department of Health
As an advocacy organization, the LTCO works directly with current residents of long-term care facilities by investigating and resolving complaints made by or on behalf of those residents. If you are contacting the LTCO about a resident who is no longer living in the long-term care facility in question, please direct your complaint to the NJ Department of Health, Division of Health Facility Survey and Field Operations, which licenses and regulates long-term care facilities. Complaint Hotline: 1-800-792-9770
DOH complaints website

Information about Mandatory Reporting
Under New Jersey law, certain individuals are legally mandated to report known or suspected instances of abuse, exploitation, crime and serious bodily injury of residents age 60 or older, in long-term care facilities as defined by N.J.S.A.52:27G-2. Any caretaker, social worker, physician, registered or licensed practical nurse, managed care representative, staff or other professional, who, as a result of information obtained in the course of his/her employment, has reasonable cause to suspect or believe that a long-term care consumer is being or has been abused or exploited, shall report such information.

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Last Updated: Tuesday, 08/31/21

Official Site of The State of New Jersey

New Jersey Long-Term Care Ombudsman

Complaint Form

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