A State-by-State Guide to Assisted Living Regulations

If you’re considering assisted living for your loved one, finding a community where they’ll be safe and have access to the highest quality of care is likely a priority. It’s normal to worry about the well-being of an elderly loved one when they’re under someone else’s care, especially as elder abuse is a real problem. However, finding information about assisted living regulations and violations can be challenging. A national website containing audit and licensing information for Medicare-approved nursing homes exists, but there’s no such resource available for assisted living facilities. 

The National Council on Aging reports approximately 1 in 10 Americans aged 60 and older have experienced some form of elder abuse, but only about 1 in 24 of these cases are reported. Knowing how to recognize signs of abuse and report assisted living violations will not only keep your loved one safe but also other potential victims.

This guide covers the types of abuse older adults are exposed to, how to report it and where you can find information about an assisted living facility’s past violations to protect your loved one from harm. 

Assisted living facilities are governed by individual states, not the federal government. Each state has its own agency that regulates ALFs, typically the state health department or social services office. The Centers for Medicare & Medicaid Services (CMS) oversees nursing homes, not assisted living communities, but offers some guidance regarding regulations of Medicaid-certified assisted living facilities. 

Assisted living communities must be licensed if they deliver high-level care to residents. Each state has its own licensing requirements, but there are a few common requirements  for these facilities:

• Daily meals
• Assistance with daily living activities
• Trained staff
• 24-hour emergency call systems and security
• Social and recreational programs
• Housekeeping and laundry services
• Transportation
• Maintenance services for resident rooms

Depending on the state, assisted living inspections are conducted annually, semiannually or as deemed necessary by the regulating agency. Advanced notice doesn’t always have to be given, especially if the inspection is in response to a complaint. When a formal complaint is filed against a facility, the state’s health department or long-term care ombudsman program will likely launch an investigation. The investigators may interview the managers or staff members and inspect safety and security measures to see if the facility is meeting regulations to maintain a healthy environment for its residents. 

Many older adults are vulnerable to assisted living abuse, especially if they have a mental impairment, such as memory loss. Elder abuse of any type can cause serious physical and psychological harm, including robbing older adults of their dignity and security or, in severe cases, costing them their lives. There are several common types of elder abuse and assisted living violations to be aware of. 

• Physical abuse: This type of abuse involves inflicting physical harm, such as slapping, pushing, hitting, kicking or improperly using restraints or denying a resident food or drinks. 
• Emotional or psychological abuse: This includes verbal abuse, harassment, degradation and humiliation. Speaking condescendingly to a resident or giving them the silent treatment for undesired actions also falls under this category. 
• Sexual abuse: Forcing an assisted living resident to engage in a sexual act, such as touching, fondling or having intercourse when they’re unable or unwilling to consent is sexual abuse. 
• Neglect: Failing to provide a resident with life necessities, including food, water, shelter, medical care or clothing, is neglect. This can either be intentional or unintentional, such as a facility being understaffed and not having the capability to adequately care for each resident. 
• Financial exploitation: This occurs when an older adult is taken advantage of financially by another individual misusing or withholding their money or other assets, usually for their own benefit. 

• Lack of daily care: A major responsibility of ALF staff is to administer daily care to residents, such as helping them with personal hygiene. Skipping a task or performing it poorly can lead to infections, discomfort and other complications that affect a resident’s overall health and well-being. 
• Mishandled medications: Failing to dispose of expired medications or refill prescriptions and giving a resident the wrong medication are some of the most common medication administration violations.  
• Poor food quality: Another common violation is storing or serving food at improper temperatures. A facility can also be cited for deviating from a resident’s dietary plan or failing to provide a scheduled meal altogether. 
• Inadequate emergency plans: ALFs should have an emergency plan in place for disasters, such as fires, floods, earthquakes or hurricanes. Failing to provide an evacuation plan is against regulations in most states, and facilities may be given a mandated time frame to bring their plan up to code. 
• Oversight of employee health: Most facilities require employees to have vaccinations for certain conditions, such as the flu and tuberculosis, to protect residents with weakened immune systems. Not keeping tabs on employee health can negatively impact a facility. 

Since there are so many types of abuse that can occur, it can be difficult to know what to look for to help your elderly relative stay safe. If you’re worried about a loved one’s condition, here are a few common signs of potential assisted living abuse:

• Unexplained bruises, broken bones, pressure marks or burns
• Poor hygiene or unsanitary living conditions
• Increased fear or anxiety
• Withdrawal from normal activities
• Unusual changes in behavior or sleep patterns
• Unusual changes in spending habits or financial documents
• Unpaid bills
• Isolation from friends or family

Assisted living abuse can go unrecognized for a long time because victims may keep details to themselves out of fear, shame or embarrassment. They may be unable to report the abuse due to a disability or lack of phone access. One of the best ways to keep a loved one safe is to visit them often. If their health or well-being is declining and unrelated to any physical or mental health conditions, or they consistently have poor hygiene and unsanitary living conditions, they may be a victim of elder abuse. 

Talking to a trained caregiver or nurse at the facility who routinely checks in on your loved one may help you determine the cause of your relative’s declining health and bring attention to their status. You can also focus on how your loved one reacts when being around certain staff members. If they seem fearful or anxious, this may be a sign they’re being mistreated. 

The process for finding information about an assisted living facility’s violation history varies by state, since each state has different regulations and laws. However, your state’s Department of Health website should be able to help. Once you get to the site, search for assisted living or adult care facilities. Depending on the site, this should bring up a facility directory or search form you can filter based on facility name or location. 

After choosing a specific facility, you should be able to access its past inspection reports. Any previous citations or violations should be included with these reports, along with other important information detailing the safety and security of the facility. If this information isn’t readily available or your state’s Department of Health website isn’t user-friendly, you can try calling the department directly and asking how you can access a copy of past inspection or violation reports. 

If you notice any signs of abuse or regulation violations when visiting a loved one at an ALF, it’s important to report it right away. Filing a complaint with the facility may be enough to resolve the issue, but in severe cases, you may need to file an official report with your state’s long-term care ombudsman program. 

When preparing an abuse or violation report, be as specific as possible about what happened. The more details you can provide of the incident, the more effectively it can be investigated. However, if you’re unsure of some details, don’t be deterred. Reporting the information you have is better than not reporting at all. To make your report as informative as possible, try to include these details:

• General statement describing what happened
• Who it happened to
• When it happened
• Where it happened
• The perpetrator of the abuse or violation
• Names of any witnesses

Providing these details can help your local long-term care ombudsman thoroughly prepare for the investigation and know exactly who to speak with at the facility. 

Each state has a long-term care ombudsman program to resolve problems regarding the health, safety and rights of individuals living in long-term care facilities, including assisted living communities and nursing homes. These programs are meant to promote policies that protect residents and ensure they have access to high-quality services and support at residential facilities. 

Whenever a resident or family member files an official abuse or violation complaint, it’s the state ombudsman program’s job to conduct an investigation and resolve the issue in the best interest of the affected resident. Depending on the state, ombudsmen may be paid staff and/or local volunteers. 

You can use the following table to identify the contact information for your state’s ombudsman program.

Below, you’ll find the websites where you can learn more about the assisted living governing departments and regulatory information in each state. Click on the state name for an overview of assisted living laws and regulations in that state.