Assisted Living Regulations: A State-by-State Guide

Covered in this guide:

• Who Regulates Assisted Living Facilities In The United States?
• Types of Assisted Living Violations and Abuse
• Recognizing Signs of Potential Assisted Living Abuse and How to Spot Elder Abuse
• How to Find Information About an Assisted Living Facility’s Past Violations
• How to Report Violations of Assisted Living Regulations 
• How To Find Assisted Living Regulations in Every State

Updated: August 14, 2023 | Reviewed by: Dr. Brindusa Vanta, MD

For many people, making the decision to move their elderly relatives into assisted living facilities is difficult. Although most people want the best care and highest quality of life for their relatives, it’s also natural to worry about seniors’ well-being when they live in a residential care setting.

Unfortunately, elder abuse can be a real concern, both for seniors and their family members. Indeed, the National Council on Aging suggests that up to 5 million older Americans experience abuse each year, with seniors who live in residential care environments especially vulnerable to mistreatment and neglect.

Although individuals can easily check complaints against and the licensing history of Medicare-approved nursing homes anywhere in the country, there is no such coordinated facility to check assisted living communities. Rather, each state is responsible for the licensing and inspection of assisted living facilities, and it can be difficult for individuals to find information.

This guide discusses the regulation and licensing of assisted living facilities and the common types of abuse and mistreatment seniors may experience while living in a residential care setting. It informs loved ones of signs to look for and questions to ask their relative if they suspect elder abuse. It also details how to report abuse and neglect and provides details of the long-term care ombudsmen program for every state.

Who Regulates Assisted Living Facilities In The United States?

Assisted living facilities are regulated at a state level rather than nationally. Each state has an agency responsible for regulating its assisted living communities, and regulations can differ from state to state.

Assisted Living Licensing

Assisted living communities must meet specific criteria to become licensed by the relevant state body. While each state has different requirements, criteria are typically stringent. Licensing generally covers aspects such as:

• Staff-to-resident ratios
• Staff training
• Medication procedures
• Tailored care plans
• Health and safety features
• Amenities

Additionally, assisted living facilities typically must provide certain services to become licensed. Such services commonly include:

• Assistance with personal care tasks
• Assistance with everyday activities
• Meal preparation
• Medication oversight
• Enrichment activities and social programming

Assisted Living Inspections

Each state's licensing body sets out minimum terms for inspections to ensure assisted living facilities are meeting the necessary requirements to maintain their license. Inspections can include a combination of routine and on-the-spot visits. Complaints generally trigger immediate inspections.

Types of Assisted Living Violations and Abuse

Per the National Institute on Aging, there are six main types of elder abuse:

• Physical
• Emotional
• Sexual
• Financial
• Neglect
• Abandonment

Families should look out for changes in their loved one’s demeanor, appearance or character.

Types of Assisted Living Abuse

In an assisted living environment, abuse and neglect may be intentional or, in some cases, result from inadequate training or staffing.

• Physical Abuse: This can involve hitting, kicking, punching, biting, hair-pulling, pushing and other physical acts. Force-feeding a resident and withholding sustenance is also a type of physical abuse. Physical abuse can occur if restraints are used inappropriately or with excessive force.
• Emotional Abuse: Bullying, verbal insults and harassment are all types of emotional abuse. Deliberately lying to residents or gaslighting them can constitute emotional abuse, as can purposely ignoring and excluding them.
• Sexual Abuse: Non-consensual sexual activity is abuse. This can involve full sexual intercourse, kissing or caressing. It can also involve making a senior perform sexual acts on another person or subjecting them to pornography.
• Financial Abuse: This occurs when a senior is taken advantage of financially, such as being made to give away cash, assets or possessions or to sign financial papers against their will.
• Neglect: Neglect occurs when a resident is given inadequate care. This may relate to cleanliness, toileting, eating and being able to join activities. It may also involve a failure to administer medications or perform therapy as scheduled. Neglect may be deliberate, though it often results from understaffing.
• Abandonment: Abandonment is when a senior is left to fend for themselves. This isn’t such a common form of abuse in assisted living facilities and is more common for those who live alone.

Common Assisted Living Violations

Sometimes, assisted living facilities fail to operate per their licensing requirements, but their failings aren’t so grave as to constitute actual abuse. Common violations include:

• Care Plans: Not following the details in a senior’s personalized care plan is a violation of assisted living licensing terms. This may relate to assistance with everyday activities, medication management and lack of enrichment activities. 
• Facility Upkeep: Facilities are responsible for carrying out repairs and maintenance in a timely manner. 
• Services: Assisted living facilities must provide all services that are included in their licensing terms. These may include regular laundry and/or housekeeping services, transportation, meal provision and daily activities.
• Health and Safety: Facilities are in breach of their licenses if they don't have adequate emergency and safety plans in place. 
• Staffing: Inadequate employee training, low staff-to-resident ratios and poor employee health may violate licensing terms. 

Recognizing Signs of Potential Assisted Living Abuse and How to Spot Elder Abuse

Abuse and mistreatment in an assisted living facility can be difficult to spot. Nevertheless, family members should look out for certain signs of elder abuse and neglect, including:

• Scratches, bruises or other unexplained injuries
• Loss of appetite
• Withdrawn, irritable, depressed or other negative changes in mood
• Sleep problems
• Dirty or unkempt appearance
• Abnormal behavior around a particular person, such as shaking, quietness or furtive eye movements
• Disinterest in activities and/or reluctance to leave the room
• Asking to return home or move to a different facility
• Reduced telephone or video calls
• Missing possessions or cash
• Caregiver never leaving relatives alone with a senior

Families may also find out useful information by talking with their loved one’s roommate or friends.

Spotting Elder Abuse

Loved ones can ask direct questions to try to uncover abuse, neglect or mistreatment. Where possible, people should ask questions when they are alone with their senior relative, such as when taking a stroll through the grounds. Seniors who can’t speak are particularly vulnerable. For such non-verbal seniors, consider having them write their answers or use an agreed code to communicate if there are any issues. Questions to consider asking include:

• Has anyone hit you or touched you without your permission?
• Do you feel safe?
• Are you able to join in freely with activities?
• Are you scared of anyone?
• Does anyone make you miss meals?
• Does anyone take your money or possessions?
• Has anyone threatened you?
• Has anyone made you sign papers you don’t understand?
• Do you take your medications regularly?

How to Find Information About an Assisted Living Facility’s Past Violations

Individuals can generally contact the relevant state licensing authority to check for any violations. Some states have online portals where individuals can find details by entering a facility’s name and address. In other states, inquirers will need to telephone the licensing body. It may also be useful to search for the facility online, as serious violations may be reported in the local press.

How to Report Violations of Assisted Living Regulations 

Seniors, their family members, caregivers and other bystanders can report any breaches of assisted living regulations. It’s vital that witnesses report any issues promptly. This not only protects the victim from potential repeated mistreatment, but also protects other residents from possible risks.

How to Prepare to Make a Report

Before making a report, it can help reporters to gather certain information, including:

• Victim’s name
• Perpetrator’s name
• Date and (approximate) time of incident
• Location of incident
• Account of what happened
• Any other witnesses

While this list can help reporters prepare to complete standardized forms and answer subsequent questions, witnesses should still make a report if they don’t know every detail.

Where to Report Assisted Living Violations and Abuse in Each State

Long-term care ombudspeople help to protect residents of long-term care residential facilities, such as nursing homes, assisted living communities and memory care units. They aim to ensure dignity, respect and high quality of life for older adults. Ombudspeople can advise seniors and their family members as to their rights and can investigate complaints related to diverse issues, including:

• Standards of care
• Abuse and/or neglect
• Resident preferences
• Health and safety
• Clinical and therapeutic care
• Meal provisions and diet
• Public benefits

Trained ombudspeople advocate for seniors and their family members and help them to resolve issues related to their long-term care. Each state has a long-term care ombudsmen program to assist individuals and receive complaints. States typically also have local or county-level ombudsman programs; state advisors can direct people to the most appropriate contact.

How To Find Assisted Living Regulations in Every State

Assisted living regulations vary between states. Individuals can find state-specific information from the agencies listed below.