A State-by-State Guide to Assisted Living Violations and Regulations

Reviewed By: Dr. Brindusa Vanta, MD

When your loved one moves to an assisted living facility (ALF), it's natural to worry about how they're doing. You want them to make new friends, enjoy a variety of activities and get the help they need to stay healthy and active. Unfortunately, elder abuse is a serious problem in the United States, and abuse occurs in ALFs just as it does in other care settings.

Although there's a national website to view the licensing history of Medicare-approved nursing homes, no such site exists for ALFs, making it difficult to choose the best environment for an older adult. What makes it even more difficult is that each state has different rules and licensing guidelines.

In June 2022, the World Health Organization released a report indicating that nearly 17% of adults aged 60 and older had experienced some type of abuse in a community setting within the previous year. As ALFs are community settings, older adults and their loved ones need to be aware of the potential for abuse when choosing one.

This guide contains information to help you recognize the signs of abuse, identify assisted living violations and report any concerns to the appropriate authorities. You'll also learn how to find the assisted living regulations for your state.

Assisted living facilities aren't regulated at the federal level. Instead, each state has its own rules regarding their licensing and operation. In some states, the department of health is responsible for overseeing ALFs. Others have a department of aging or elder affairs to manage the licensing process.

Since every state has different regulations, the licensing process varies from one to another. These are some of the most common requirements:

• Meal services: ALFs typically have to serve three meals per day. Some states also limit the number of hours between the end of the evening meal and the start of breakfast the next morning.
• Assistance with activities of daily living: ALFs are typically required to provide some level of assistance with ADLs. These are the skills older adults need to care for themselves, such as walking, getting dressed and maintaining their personal hygiene. 
• First aid and fire safety: Many states require ALFs to train staff members to provide first aid and respond to fires and other emergencies and have a minimum number of emergency exits or meet other fire safety regulations.
• Medication storage: Nearly 90% of adults aged 65 and older take at least one prescription medication. To protect seniors from adverse events, many states have regulations governing medication storage in ALFs.

Each state also has inspection requirements for ALFs. Before an ALF opens, the state agency may conduct an initial inspection, which helps verify that the facility is safe for residents. Many states also require annual inspections to verify an ALF's compliance with regulations. Inspections may occur more frequently in response to complaints from residents or family members.

The National Council on Aging estimates that about 10% of seniors have experienced some type of abuse. Violations of ALF regulations also put residents at risk, even if they aren't technically classified as abuse.

When you hear the word "abuse," you probably think of punching, kicking and other types of physical contact that results in pain or injury. While this does occur in some senior living communities, staff members, visitors and even other residents may also perpetrate the following:

• Emotional abuse: Abusive individuals may threaten, intimidate or harass residents without physical contact.
• Financial abuse: This occurs when someone uses a senior's money or other resources without permission. They might steal an older adult's checkbook, open credit accounts in their name or take cash from their assisted living apartment.
• Sexual abuse: This can take many forms, such as fondling an older adult without their consent or having intercourse with a senior who doesn't have the capacity to consent. It may also include forcing them to remove their clothing or taking explicit photographs without their consent. 
• Confinement: Some perpetrators get away with their abuse by confining or isolating their victims. This may include locking a resident in their room, using physical restraints or administering sedatives to keep them quiet.
• Passive neglect: This occurs when a caregiver fails to provide medical care, food, clothing or other necessities.
• Willful deprivation: A caregiver may willfully deny an older adult medication, assistance with ADLs, medical care and other necessities. 

Even if assisted living violations don't necessarily meet the definition of abuse, they can put residents at risk of harm. These are some of the most common violations noted on inspection reports:

• Food-related violations: ALFs must follow state and local laws regarding food preparation and storage. If a facility doesn't follow these laws, residents may be exposed to foodborne illnesses.
• Medication-related violations: ALFs have been cited for having expired medications on hand, not storing medications according to regulations and failing to label them appropriately.
• Employment violations: Most states set minimum requirements for ALF administrators and employees. ALFs may violate these regulations by failing to run background checks on new employees, hiring individuals with criminal histories or failing to verify that staff members are in compliance with training requirements.
• Emergency preparedness: A fire, flood, earthquake or other emergency can happen at any time, so most states require ALFs to have written emergency plans. Some agencies also require regular emergency drills to ensure that residents can escape quickly. An ALF that violates these regulations may be fined or face other penalties.
• Communicable disease prevention: In older adults, the immune system is weaker, therefore they have increased risk of various infections. Certain medications also suppress the immune system. To prevent the spread of communicable diseases, some states require ALF employees to get an annual flu shot or undergo tuberculosis testing at regular intervals. Facilities that violate these rules put residents at greater risk of contracting serious illnesses.

Once your loved one moves to assisted living, it's important to visit regularly and look for potential signs of abuse. Each type of abuse has different warning signs, but here are a few of the most common:

• Unusual bruising, such as bruises around a resident's wrists
• Reports of abuse from your loved one or another resident
• Injuries that can't be explained by an unexpected fall or other type of accident
• Signs of neglect, such as poor hygiene or unintended weight loss
• Unexplained scars or burns
• Changes in behavior, such as a sudden withdrawal from normal activities

The signs above are closely associated with physical abuse, emotional abuse and neglect, but it's also important to watch for indications of financial abuse, willful deprivation and confinement. Look for the following when you visit your loved on

• Missing checkbooks, cash or financial documents
• New accounts appearing on your loved one's credit reports
• The addition of a staff member's name on your loved one's bank account or credit cards
• Unauthorized ATM withdrawals
• Missing valuables, such as jewelry or expensive artwork

• Sudden weight loss that can't be explained by a medical condition
• Discrepancies in the number of pills in your loved one's medication organizer
• Reports from your loved one or another resident about staff members withholding food, medical care or medication
• Signs that your loved one isn't receiving assistance with ADLs, such as ragged nails or tangled hair

• Marks from physical restraints around the wrists or ankles
• Confusion or other signs that your loved one has been overmedicated
• Reports from your loved one about staff members locking them in their room or isolating them from other residents and visitors

Inspection reports are typically published online, making it a little easier to gather information about specific ALFs. Although the process varies from state to state, you can generally access information about past violations by following these steps:

• Find out the name of the regulatory agency in your state.
• Navigate to the agency's website.
• Use the online search tool to search for terms like "violations," "citations" or "inspections."
• Search by ZIP code or facility name.
• Review multiple reports carefully to determine if past violations are minor or serious.

If you notice any assisted living violations or signs of abuse, it's important to report them immediately. Below are the steps you should take before making a report to a regulatory agency or ombudsman.

Before you make a report, gather as much information as possible. You may not know every detail, but the more information you provide, the easier it will be to convince someone to investigate. Be prepared to include the following in your report:

• The date(s) of the incident(s)
• The name of the perpetrator, if known
• Whether the perpetrator is a staff member, resident or visitor
• What actions you've already taken to address the issue
• Where the incident occurred
• The names of any witnesses, if available