Federal and State Nursing Home & Assisted Living Regulations Transparency, Safety and Living Resources for All 50 States

Last Updated: September 2020

COVID-19 exposed many vulnerabilities in assisted living and nursing homes, causing some seniors to reconsider moving in. This guide explores the federal and state regulations in place for these communities, especially regarding cost, health and safety. It also discusses enforcement and how to get data on how closely a facility follows regulations.

Table of Contents

Nursing Home vs. Assisted Living: The Differences Matter

Many folks use the terms, “nursing home” and “assisted living,” interchangeably. This is understandable, especially since some assisted living facilities provide memory care or low-level nursing care. However, the distinction matters quite a bit, especially with regulations and cost.

Some quick background: Skilled nursing facilities and assisted living facilities are part of the many Continuing Care Retirement Communities (CCRCs) across the United States. These communities offer a continuum of housing and care so residents can stay in the same place if their needs change or live near a spouse with different care needs. Of course, plenty of standalone skilled nursing facilities exist, as do standalone assisted living facilities.

State Medicaid programs for assisted living may require that participants meet what’s called a “nursing home level of care.” That doesn’t mean these folks need skilled nursing care around the clock. Rather, it typically means they cannot perform two of the activities of daily living (eating, bathing, dressing, mobility/transferring, continence and toileting). Criteria varies by state and program. For example, one state may require the inability to perform two ADLs, while just one ADL suffices in another state.

If you have second thoughts about entering a nursing home, chances are you mean assisted living and not skilled nursing. (Because you have the time to consider living options, you’re probably not dealing with a current health emergency that led to hospitalization.) Check out the table below for a refresher on the differences.

Table 1: Differences Between Skilled Nursing and Assisted Living

Skilled Nursing Facility

Basic Definitions

Also called nursing facilities, skilled nursing and rehab. Can be part of hospitals.

24-hour medical and personal care, both short term after hospitalization (like after surgery or a bad fall) and long term (for chronic issues). Rehabilitation services such as physical therapy and speech therapy are available.

Because skilled nursing homes involve medical care, costs are higher. The regulations, licensing, staffing and training requirements are stricter than in assisted living.

In a Continuing Care Retirement Community, skilled nursing and rehab care is the most intensive care type unless memory care is offered.

Regulation

Must follow federal regulations for certification by the Centers for Medicare and Medicaid Services (CMS).

Some states add their own regulations but cannot subtract from federal regulations.

Each state conducts surveys, which are unannounced inspections at least once every 15 months, to ensure compliance.

Comparisons and Compliance

Nursing Home Compare is a Medicare tool that assigns five-star quality ratings based on health inspections, staffing and quality measures. It also gives details on certification, ownership and whether the facility is part of a CCRC. You can read full inspections reports on nursing homes (“View full report” with “Date of most recent health inspection”).

Nursing Home Inspect is another useful tool. It works with the same data that Medicare Compare does but organizes the information differently.

Decision to Live There and Living Situations

Often forced by a health emergency such as a fall that requires hospitalization and subsequent rehab. Seniors have little time to evaluate their options unless the skilled nursing facility is part of a CCRC decision made in advance of the health emergency. Otherwise, a chronic health issue requiring medical care may force the move to a nursing home.

Seniors typically have roommates and little to no say in choice of room. Regulations do require that seniors receive advance notice of room and roommate changes in a language they understand. (For more on room change regulations, read under “Room Changes” here. Note that Nevada has added some of its own state regulations under “Discharges.”)

Activities and socialization opportunities are common (or supposed to be).

Payment and Costs

Average semi-private room cost of $7,513 monthly;

$8,517 for private.1 More expensive than assisted living.

Medicare can pay for short-term rehab in Medicare- certified skilled nursing facilities. These stays occur after a qualifying three-day hospitalization. If you have a Medicare Advantage plan, the rules may be different, so check with the plan provider.2

Up to 100 days per benefit period are covered. It’s up to seniors and their caregivers to track how many days are left in the period. The first 20 days are 100% covered. You pay (or find other payment sources) for $170.50 per day for days 21-100, and Medicare covers the remaining balance.

After 100 days, residents are responsible to pay in full, whether out of pocket, through Medicaid, long-term care insurance or other means.

Medicare covers up to another 100 days if seniors have been out of the hospital or skilled nursing facility for 60 consecutive days and have another qualifying three-day hospitalization.

Assisted Living Facility

Basic Definitions

Also called adult foster care, personal care homes and other terms, depending on the state.

Residents need help with the activities of daily living (ADLs) such as bathing, moving around and eating. The degree of assistance needed can range from a little to a lot.

Some assisted living facilities offer memory care and low- level medical services such as diabetes monitoring.

Regulation

Regulated on the state level, with regulations and enforcement varying widely from state to state.

Inspections in many states are required every 12 or 24 months, but intervals include 6 months, 36 months and even 60 months.

Comparisons and Compliance

A long-term care ombudsman can help you investigate an assisted living facility’s track record (same with nursing homes).

Check your state’s licensure agency for assisted living (more on this in Table 2). In some states, detailed breakdowns of surveys or the reports themselves are available. Always pay attention to the date of the inspection. The further off it was, the less reliable or relevant the data might be.

Decision to Live There and Living Situations

Sometimes forced by a health issue, but seniors frequently have more time to consider and compare their assisted living options.

The size and scale of communities vary. Some communities are in actual homes, in large buildings or somewhere in between.

Depending on the facility, seniors can choose between living arrangements such as a studio and one-bedroom apartment. Bathrooms may be private or shared.

Activities and socialization opportunities are common (or supposed to be).

Payment and Costs

Average cost of $4,051 monthly.1 In most states (but not all), Medicaid may pay for services in Medicaid-certified assisted living facilities. Some facilities are private pay only and do not accept Medicaid.

SSI (and optional state supplements) can help with room and board costs. Many Medicaid-certified facilities aren’t allowed to charge more than the federal SSI rate + any state supplement for room and board.

Seniors must have limited income and assets to qualify for Medicaid unless they participate in some type of partnership long-term care policy with their state.

Other ways to pay include veterans’ benefits, long-term care insurance and self-pay.

Medicare does not pay for assisted living but sometimes pays for medical/skilled nursing care services received in assisted living.

More on comparisons: If the facility you’re considering is part of a CCRC, check both the Medicare comparison tool and your state’s assisted living inspection reports (if accessible). Do this even if it’s just the skilled nursing aspect or the assisted living aspect you care about.

Looking at both gives you a more rounded picture of how well the CCRC follows regulations. For example, some of the same staffers may work in both assisted living and nursing care. Residents from both may socialize with one another, too. That’s one reason CCRCs appeal to couples with different care needs. They no longer live in the same room or apartment but are close together for meals and socialization.

A third tool to use is ProPublica’s Nursing Home Inspect. It draws from the same CMS data that goes into the Medicare comparison tool but is organized differently. For example, there are state pages such as Michigan’s that enable comparisons among all nursing homes in the state. At a glance, you get total deficiencies, serious deficiencies, fines and even COVID-19 cases (as of September 2020). Unfortunately, there’s no similar tool for assisted living since it is state regulated.

State Regulations and Transparency for Assisted Living

Every year, the National Center for Assisted Living (NCAL) publishes the Assisted Living State Regulatory Review. It summarizes the key requirements that assisted living facilities in each state must meet to gain or maintain licensure/certification. Take a look at your state so you have a good idea of the standards there. The review covers issues such as:

  • The state’s definition of assisted living and any specialty licenses offered
  • If there are differing levels of assisted living care provided
  • Recent legislative or regulatory changes
  • Disclosure items for prospective residents
  • Scope of care
  • Third-party scope of care
  • Admission and retention policies
  • Resident assessments
  • Medication management
  • Square feet requirements
  • Residents allowed per room
  • Bathroom requirements
  • Life safety
  • Unit and staffing requirements
  • Administrator education and training
  • Staff education and training

Take the time to study disclosure items. For example, disclosures are where you should be able to find figures on charges and fees. Other rules and regulations to pay special attention to include these:

Resident assessments and their frequency: Staffers should conduct a needs assessment when a new resident is admitted. The assessment aids in the development of a personal care plan. Re- assessments are supposed to be done about once a year and when a resident’s needs change (as is common with aging and after hospitalizations).

Medications: Who is allowed to administer medications, what is the level of assistance allowed and what happens if a resident doesn’t agree with taking medications or doesn’t want to? Many facilities can cut ties with residents who refuse medication. Generally, though, residents have the freedom to make their own medical decisions.

Care cutoffs: These cutoffs address the sometimes fine line between assisted living and nursing care. To give a basic example, some assisted living facilities assist in diabetes management, performing glucose monitoring, toenail clipping and other services for a fee. However, intensive, ongoing medical care needs are more likely to be the purview of skilled nursing homes.

 

Staffing and administrators: These regulations address training and educational requirements and whether the person (or people) on site overnight are required to be awake.

Let’s look at Florida briefly. According to the 2019 NCAL report, a Florida assisted living facility must disclose to potential residents its admission and continued residency criteria, residency charges, personal care services and charges, any nursing services provided and their charges, social and leisure activities, and accommodation of special diets, among other things.

Florida has three special license types for assisted living: extended congregate care for more intensive care, including nursing services to frail residents; a limited nursing services license; and a limited mental health license. Assisted living administrators must have a high school diploma or GED and must complete core training. (In some other states, the requirements are higher-level.)

The NCAL review doesn’t explain about enforcement and where to find out about facility compliance. Fortunately, it’s pretty easy to research violations in Florida. It isn’t in some other states.

Head to the Floridahealthfinder.gov Facility Locator site and choose “Assisted Living Facility.” Type the address or ZIP code for facilities you want information on. From there, you can read the most recent inspections reports and statements of deficiencies.

Review the table below (“State-by-State Assisted Living Transparence”) for details on how transparent and accessible facility-specific information is. Regulations are of little import if you can’t find out whether a facility follows them. The table also features a column addressing the frequency of inspections. The more often inspections take place, the more reliable and recent the inspections data is.

To see actual assisted living rules and regulations, check the “Citations” section at the end of each state’s NCAL summary. They can make for intensive, hours-long reading but may be more illuminating than summaries.

As you’ll see from the table, many states don’t go out of their way to make assisted living records accessible. Some do make it fairly easy to file open records requests, even providing online submission forms. Otherwise, check out these state FOI (freedom of information) resources for filing a request.

Important: All states are required to have a long-term care ombudsman. Your local or state ombudsman office should be able to help with FOI requests and background information on assisted living facilities and nursing homes. To find offices, check out this map.

Table 2: State-by-State
Assisted Living Transparency

Alabama

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good. Reports and info on violations are easily accessible online.

Frequency of Inspections: Every 24 months

Alaska

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic transparency. Bare bones online information only lists whether facilities are licensed. No data on inspections, violations, etc.

Frequency of Inspections: Every 24 months

Arizona

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 12 months

Arkansas

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic as far as finding out info on inspections and violations. You must be an Arkansas resident and submit a written request for the data.

Frequency of Inspections: Every 24 months

California

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 36 months (three years)

Colorado

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good, although inspections are too infrequent

Frequency of Inspections: Every 24 months

Connecticut

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

  • Connecticut License Lookup to verify if a facility is licensed and to read reports.
  • Choose Assisted Living Service Agency. Some of the facilities that show up may not have inspections reports yet. To review a facility, click on “Detail” and then “Document Link” for the survey report.
  • Department of Public Health for regulatory action orders and regulatory action reports.

Standards for Transparency, Licensing and Certification:

Problematic since the state doesn’t have the ability to fine a facility for violations.

Also, the state doesn’t exactly license the facilities themselves, instead licensing assisted living services agencies.

Not all facilities have survey reports posted online.

Frequency of Inspections: Every 12 months, but info online may be years out of date

Delaware

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic. Inspections reports online (as of August 2020) are years out of date. The most recent information is from 2015. It would be better if the state took these links down altogether rather than possibly mislead people into thinking the info is recent.

Frequency of Inspections: Every 12 months, but the reports online are probably out of date.

District of Columbia

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic. Inspections reports (surveys) online are likely to be out of date by several years even though inspections are required every year.

FOIA requests may be necessary for more recent data.

Frequency of Inspections: Every 12 months

Florida

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 16 months

Georgia

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Pretty Good. Most, if not all, of the info accessible online, but search results can seem jumbled.

Input all of the information you have—facility name, address, phone number, etc. to eliminate extraneous results.

Frequency of Inspections: Every 6 months to 1 year

Hawaii

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good. Hawaii has inspections reports available online, but it’s easy to overlook the most recent one. You may need to look farthest right on your computer screen for the link.

Frequency of Inspections: Every 12 months

Idaho

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Great. Star system helps exceptionally safe facilities stand out (gold star if no deficiencies, silver star if three or fewer non-core deficiencies).

Frequency of Inspections: Every 12 months

Illinois

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic. You can find out online whether a facility is licensed, but that’s about it. For more details, get in touch with the ombudsman’s office. FOIA requests may be necessary.

Frequency of Inspections: Every 15 months

Indiana

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

  • Health Care Facility Consumer Information map

    Choose “Residential Care Facilities” from the “Find a Provider” search box or enter a facility name. Click on “View Consumer Report” for info on inspections.

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 24 months

Iowa

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

  • Entity Search
  • For entity type, choose ALP (Assisted Living Programs). Click “View” and “View Report” for specifics.

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 15 months

Kansas

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 24 months

Kentucky

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic. Only bare-bones licensing info is accessible online.

Frequency of Inspections: Every 12 months

Louisiana

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic. Just the bare bones licensing information is accessible online.

Frequency of Inspections: Every 24 months

Maine

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic. The bare minimum is all that’s available online.

Frequency of Inspections: Every 15 months

Maryland

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

  • Consumer Guide to Long Term Care for a variety of information, including pricing. Only applicable to facilities with 10+ beds.
  • Click on “Facility Name” in the left column of results to learn more. Inspection details bring up deficiency issues such as emergency preparedness, medication management or delegating nurse, although reports themselves may not be available. (Contact AL.HELP@maryland.gov or call 410-402-8217 for further details.)
  • Minimum licensing and contact info is available through the state’s licensee directory (includes facilities with fewer than 10 beds)

Standards for Transparency, Licensing and Certification:

Uneven.

Pro: Maryland lists pricing information, which is nearly unheard of.

Con: The consumer guide doesn’t break down inspections reports for facilities with fewer than 10 beds. Contact the ombudsman or AL.HELP@maryland.gov or call 410-402-8217 for assistance.

Frequency of Inspections: Every 24 months

Massachusetts

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic. No information on inspections is available online.

Frequency of Inspections: Every 24 months

Michigan

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good.

Michigan doesn’t license assisted living communities per se, instead licensing homes for the aged and adult foster care.

Inspections reports are readily available online. However, you must submit a FOIA request to see a facility’s plan of correction.

Frequency of Inspections: Every 12 months

Minnesota

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic. Bare-bones licensing information is accessible but that’s about it (a lot more is available on nursing homes).

Frequency of Inspections: Every 24 months

Mississippi

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

  • Health Facilities Directory PDF of licensed facilities.
  • Do a find and search for the “Assisted Living” column or use a facility name.

Standards for Transparency, Licensing and Certification:

Problematic. The bare minimum licensing info is accessible online.

Frequency of Inspections: Every 6 months

Missouri

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Great. Plus, Missouri assisted living facilities get inspected every six months, so the data is quite recent.

Frequency of Inspections: Every 12 months

Montana

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 60 months (five years)

Nebraska

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

  • License Information System Search for licensure, inspections and violations data under “Facility/Service Search.”
  • For disciplinary actions, call (402) 471-2115.

Standards for Transparency, Licensing and Certification:

Problematic. Inspections are required only every five years. That’s a lot of time for a facility to fall out of compliance.

On the bright side, survey results are easily accessible online.

Frequency of Inspections: Every 12 months

Nevada

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good. Nevada even assigns letter grades such as “A” and “F” to facilities. Critical information about facility safety is easily accessible online.

Frequency of Inspections: Every 12 months

New Hampshire

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

  • New Hampshire Online Licensing, Look Up a Business License
  • Choose “Health Facilities” and then “Assist Living/Residential Care Facility”
  • Contact (603) 271-9039 if no statement of findings is available.

Standards for Transparency, Licensing and Certification:

Pretty good but a bit Uneven.

For most facilities, you can read about violations and corrective plans—but they don’t seem to be listed with every facility that had violations.

Frequency of Inspections: Every 12 months

New Jersey

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

  • Search for Long-Term Care Facilities to check on licensure.
  • Use an ombudsman or OPRA (the New Jersey Open Public Records Act) to get more information if necessary. OPRA links usually show up if the relevant record is not available.

Standards for Transparency, Licensing and Certification:

Pretty good but a bit Uneven. Most of the data on inspections and violations is readily available. Click on “More info” next to inspections and complaints and then on ID numbers.

Every once in a while, you may come across an instruction to use OPRA to get the relevant record.

Frequency of Inspections: Every 12 months

New Mexico

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

  • Health Care Provider Search for licensed facilities and select survey reports.
  • For more reports and information, contact the Health Facility Licensing and Certification Bureau at (505) 476-9047 or (505) 476-9025

Standards for Transparency, Licensing and Certification:

Problematic. The survey reports posted online may be out of date, sometimes by a little, sometimes by a lot. Don’t count on the most recent inspection report (within the past 12 months) to be available.

Frequency of Inspections: Every 12 months

New York

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good. The only issue is that full inspections surveys aren’t available online. Instead, just the citations are offered. For most people, it’s enough to get the idea of how well a facility follows regulations.

Contact an ombudsman or file an open records request for the records themselves.

Frequency of Inspections: Every 24 months

North Carolina

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good. Info is comprehensive and easy to find but may be slightly outdated due to inspections required every two years.

The star rating system and the scores give a good idea at a glance how reliable a facility is.

Frequency of Inspections: Every 24 months

North Dakota

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic. North Dakota offers a PDF list of assisted living facilities but that’s about it. (It’s much more robust with nursing home transparency.)

Frequency of Inspections: Every 9 to 15 months

Ohio

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic. Just bare-bones licensing info is available online.

Plus, Ohio doesn’t have the authority to fine assisted living communities.

Frequency of Inspections: Every 12 months

Oklahoma

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 24 months

Oregon

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 12 months

Pennsylvania

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 24 months

Rhode Island

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Uneven. You can find basic licensing information online, but inspections reports are available for just some facilities.

Frequency of Inspections: Every 24 months

South Carolina

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

  • Facility Locator
  • Contact an ombudsman or submit FOIA requests for facility records.

Standards for Transparency, Licensing and Certification:

Problematic. Information on facility inspections and violations is not accessible online.

Frequency of Inspections: Every 12 months

South Dakota

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic. Information on assisted living facility inspections and violations is not accessible online.

Frequency of Inspections: Every 15 months

Tennessee

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Uneven. You can see which facilities have disciplinary actions. However, inspections reports are not available as a default.

Frequency of Inspections: Every 24 months

Texas

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good. You can get an idea of how well a facility follows regulations, although inspections reports themselves may not be up.

Frequency of Inspections: Every 36 months (3 years)

Utah

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Problematic. Virtually nothing is accessible online. You’ll have to go through an ombudsman or FOI request for details, and inspections are spaced too far apart.

Frequency of Inspections: Every 12 months

Vermont

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 12 months

Virginia

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good. Virginia offers data on complaints and violations since 2003. The inspections reports themselves are not online, but there is detailed information on non-compliance.

Frequency of Inspections: Every 12 months

Washington

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 12 months

West Virginia

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good

Frequency of Inspections: Every 6 months

Wisconsin

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Good. PDFs of facilities even list low/high pricing rates.

Frequency of Inspections: 36 months (3 years)

Wyoming

State and Assisted Living Main Links:

Links to Assisted Living Facility Licensure and/or Compliance:

Standards for Transparency, Licensing and Certification:

Uneven. Info is easily accessible, but Wyoming doesn’t have the ability to fine an assisted living facility. Inspections are required only every 36 months.

Frequency of Inspections:

Some assisted living homes are unlicensed. That is, they haven’t submitted the necessary forms for state approval. They haven’t undergone fire safety inspections and other required inspections. It’s anybody’s guess if they’re properly staffed and whether staffers are vetted.

Unlicensed facilities can be safe, but they don’t have state approval. Be extra careful if considering unlicensed facilities.

Medicaid, Assisted Living and Spotty State Regulations

About half of assisted living facilities are Medicaid-certified to accept Medicaid funds. The money goes toward help with the activities of daily living and other services. Medicaid doesn’t pay residents’ rent, but residents can use SSI to partially or fully pay that expense.

  • Medicaid assisted living qualifications and coverage vary by state depending on factors such as your age, marital status, where you currently live, and your income and assets.
  • Many states cap the dollar amount that a Medicaid-certified facility can charge, and it’s similar to SSI rates.
  • Medicaid waiver programs are “waivers” from regular program requirements. Among other things, waiver programs can raise income thresholds to let higher-income seniors qualify for assistance. However, these programs have limited slots and may cover only certain regions of a state.
  • Waiver programs can end. A new program may or may not replace an older one.
  • Alabama, Kentucky, Maine, Pennsylvania and Virginia have Medicaid programs that don’t pay anything for assisted living (or their programs are so limited as to disqualify the majority of low- income and low-asset seniors). However, these states may have Medicaid programs that help seniors stay at home or receive care in a residence such as an adult foster home.
  • Alabama: No Medicaid assistance for seniors in assisted living but offers programs to help seniors stay in their homes.
  • Kentucky: The Supports for Community Living Waiver covers adult foster care, but seniors must have become disabled with intellectual or developmental issues before age 22.
  • Maine: No assisted living assistance, but MaineCare can help seniors remain in their homes.
  • Pennsylvania: Medicaid assistance is available to seniors in domiciliary care homes/adult foster care (not assisted living).
  • Virginia: No Medicaid assistance for seniors in assisted living, although assessments are available through the Virginia Adult Services Program.

Medicaid, SSI and Financial Qualifications

If you’re applying for regular state Medicaid, expect stricter income requirements (your income must be lower). If you’re applying for a waiver program, you have more income flexibility. If you’re already on Medicaid and apply for a waiver program, you may be fast-tracked.

Here’s a link to a Washington state Medicaid eligibility chart. (For assisted living, the “Medicaid Waivers / Home and Community Based Services” boxes may be more relevant. However, you can get an assessment to see if your care needs are more intensive.) Check out other states here.

What if you’re over the income or asset limits? A good option is to meet with an elder planning or estate planning lawyer. See how you can comply with federal and state regulations while working toward Medicaid eligibility.

Other options for checking eligibility are to go to Benefits.gov and click on your state program (to get there, choose “Healthcare and Medical Assistance” and then “Medicaid and Medicare”). Enter your household size to see if your income falls within Medicaid guidelines. The page also has links to apply online for Medicaid and to contact staffers for assistance.

Some assisted living facilities that accept Medicaid require that you pay a certain amount up front before Medicaid kicks in (for example, the first three months of services might need to be out of pocket). Always ask facilities and your local area agency on aging about these issues.

Many seniors use monthly SSI payments to cover room and board in assisted living. As of January 2020, the federal SSI benefit rate is $783 for an individual and $1,175 for a couple.3 Many states offer additional supplements to seniors in assisted living, so check with your state or federal SSI office (see this link to determine which office to contact).

The following states do not offer additional supplements to anyone, including assisted living residents. However, they may cap room and board charges in Medicaid-certified assisted living facilities to just below the federal SSI rate. (Many other states do this too, even if they offer additional supplements.)

  • Arizona
  • Northern Mariana Islands
  • Mississippi
  • West Virginia
  • North Dakota

California is a state that supplements base SSI income for assisted living residents. It also caps the amount that Medicaid-certified facilities can charge. As the state explains about its Non-Medical Out-of- Home Care Rate (NMOHC) program:

A single person living in an RCFE and eligible for SSI would receive the $1,206.37 NMOHC benefit, pay $1,069.37 to the facility for rent, and keep $137 as his/her Personal and Incidental Needs Allowance (PNA). A couple both on SSI/SSP and living in the same facility would receive the NMOHC rate of $2,412.74, pay $2,138.74 to the facility for rent, and keep $274 each month as their PNA.

Rhode Island’s SSI Enhanced Assisted Living program is one that addresses assisted living specifically.

Another intriguing program, although it’s not SSI-specific, is Alaska’s Pioneer Homes. These homes are state-owned and state-operated assisted living communities. They keep costs lower than private facilities would and offer various types of financial assistance.

Medical Qualifications for Assisted Living

You must qualify medically for Medicaid/a waiver program to pay for assisted living services in any form. Often (and confusingly), you must meet what’s called a “nursing home level of care.” That doesn’t mean you need skilled nursing facility care or similar 24-hour medical care. Rather, in many states, it means you can’t perform at least two of the activities of daily living. Criteria varies by state and program, so one state may require the inability to do two ADLs, while just one ADL may suffice in another state.

It is usually professionals such as nurse practitioners and social workers who certify you’re unable to carry out these ADLs. Get started as soon as possible to expedite the process and save money. Ask your physician to refer you for an assessment or to otherwise get the ball rolling.

Spousal Protection, Assisted Living and Nursing Homes

If you’re married, Medicaid spousal protection rules can help a healthy spouse continue to live at home instead of becoming impoverished to pay for the other spouse’s assisted living or nursing home care. More commonly, it’s nursing home care but applies to some assisted living situations. Here are Wisconsin’s spousal impoverishment regulations as an example.

You can continue to receive SSI. Check out the 2020 SSI and Spousal Impoverishment Standards here. The community spouse is the one who continues to live at home or otherwise in the community.

Other Medicaid Financial Regulations for Assisted Living and Nursing Homes

  • Medicaid may make future claims against your estate but usually isn’t allowed to collect until after the community spouse dies. If you have minor children or children with disabilities, Medicaid might not collect.
  • Beware of the Medicaid lookback period. It’s the five years prior to your Medicaid application date. It is meant to prevent situations such as you transferring all your assets to your adult children the day before you apply for Medicaid. If there was no lookback period, the states would experience a lot more financial strain paying for long-term care.
  • Retirement accounts are generally not counted under lookback period rules. They’re instead considered sources of income. So, you could have $110,000 in your retirement accounts and still qualify for Medicaid.4

Assisted Living Disclosures and Costs

Assisted living facilities must give prospective residents disclosure documents that detail the charges and fees for the different services available. This information should be in contracts, too.

If you’re just in the search stage, you’ll have to contact facility administrators to get specifics on charges. Only two states’ assisted living websites offer data on facility pricing (Maryland and Wisconsin). Cost is definitely something to pay extra attention to in disclosure documents and during conversations with administrators. Also, look over the sections having to do with eviction so you understand what happens if you cannot pay any longer.

When you’re about to sign a contract, review it carefully. Too many folks seal the deal in a hurry and don’t fully understand everything they’re on the hook for.

  • If necessary, meet with an elder law attorney for a fuller picture of regulations, costs and how you might be able to protect your assets—both in the short and long term. Lawyers can be helpful whether you’ve yet to sign a contract or already have.
  • Search for assisted living resources such as Medicaid and other types of financial assistance, using the “Paying for Assisted” living tab on the National Center for Assisted Living (NCAL) website.
  • Your local Area Agency on Aging can assist in finding out about the services and regulations in your state and locality, get you assessed, and tap into potential sources of financial assistance.
  • Many residents need assistance or services that go beyond base rates.
  • Personal expenses such as cable TV may not be covered under rate plans.
  • The facility might offer an all-inclusive price that is perhaps cheaper than paying for services individually.
  • It’s not always easy for assisted living facilities to make a profit or pay their staffers a fair wage, so many places have multiple pricing tiers or individual charges for services. Charges that you didn’t expect should be outlined in the contract. If they are not, contact the facility or seek legal advice.
  • Medicare might pay for some nursing medical expenses in assisted living but won’t pay for personal care services, custodial care or room and board.
  • Medicaid does not pay room and board, but SSI can go toward these expenses. In many states, Medicaid covers services such as help with the activities of daily living.
  • Medicaid regulations governing long-term care and cost can be complicated, with lots of regular and waiver programs. For an idea, look at Washington state’s long-term care manual (the Medicaid home and community services page is also relevant).

Long-Term Care Insurance Policies

State laws vary as to whether certain long-term care insurance policies are legal in the state. Always be diligent if choosing long-term care insurance.

 

 

Many states such as New York allow Medicaid asset workarounds (partnership long-term care policies). They work if a person has already purchased a state-sponsored long-term care insurance policy, it’s run out, and the person now needs Medicaid funding. The person can keep most or all of their assets.

Regulations for Nursing Homes

It can be tough to uncover information on assisted living facilities. Thankfully, finding data on nursing homes is easier. These two tools are excellent starting places:

Nursing Home Compare on Medicare.gov (read inspections reports, too)

Nursing Home Inspect on ProPublica

Nursing homes must keep a lot of federal rules, regulations and recommendations in mind (plus some states add their own). Oversight to some extent is necessary, although it’s debatable to what extent. At some point, do regulations become more of a burden than a help, burying nursing homes under growing mounds of paperwork and taking away from time with residents?

Whatever your thoughts, there’s no question that before regulation, which began in the late 1960s, care quality was poor. The 1987 Nursing Home Reform Act established requirements in three main areas: service provision, residents’ rights, and administration and other matters. Further reforms followed with the 2010 Affordable Care Act and with the rollout of even more regulations in 2016. The 2016 requirements in particular were supposed to strengthen infection controls, emergency preparedness and facility assessment. Unfortunately, COVID-19 still hit many nursing homes hard.

The pandemic has led CMS to issue guidance on topics such as screening and restricting visitors, setting aside separate units for COVID-19 patients, and testing residents and staff. CMS has also issued recommendations and a toolkit with best practices for each state.

Health Regulations

A main health regulation in nursing homes is that the facility (and the care given in the facility) cannot be the reason a resident’s health or quality of life has declined.

Nursing homes participating in Medicare and Medicaid must follow the residents’ rights enshrined in the 1987 Nursing Home Reform Law.5 Among other things, these rights govern participation in one’s own care, privacy and confidentiality, transfers and discharges, visits, dignity, respect and freedom, and independent choices.

Regulations require that you have a care plan prepared by you (if possible), your family or someone you designate, along with nursing home staff. You undergo regular health assessments to determine the personal and health care services you need, how often, who should administer them, necessary equipment and supplies, the best diet for you and goals for returning to the community, among other things.6

Cornell Law School’s website hosts a copy of 42 U.S. Code § 1395i–3 – Requirements for, and assuring quality of care in, skilled nursing facilities. The sections touch on issues such as:

  • Sufficient nursing staff
  • Assessments of each resident’s functional capacity
  • Comprehensive care plans for each resident
  • Personal care services such as feeding, grooming and hygiene, if necessary
  • Treatment and assistive devices for vision and hearing
  • Prevention and treatment of pressure sores
  • Assistance with incontinence
  • Sufficient nutritional and fluid intake
  • Quality of life
  • Resident rights to choose health care, schedules and activities
  • Pharmaceutical services
  • Maintenance of accessible, complete and accurate resident records
  • Requirements for surveys and Nursing Home Compare

Infections and COVID-19

A Government Accountability Office report published in May 2020 found that infection control deficiencies were widespread and persistent before COVID-19. One part of it reads:

Prior to the COVID-19 pandemic, we found that most nursing homes were cited for infection prevention and control deficiencies (82% of those surveyed from 2013-2017). About half of these homes had persistent problems and were cited across multiple years. 7

This is troubling on multiple fronts, for example, the problem itself and then the high number of repeated failures to correct it. So, what happens when a nursing home is out of compliance? What penalties, if any, prod the facility to do better? The following section touches on these issues.

When Nursing Homes Do Not Comply with Rules

If a survey finds that nursing homes are out of compliance, what happens depends on how serious the non-compliance is. An immediate jeopardy finding means that temporary management could be appointed while the nursing home remedies its deficiencies. Otherwise, the facility is terminated from the Medicare and Medicaid programs and the residents moved elsewhere.

  • Immediate jeopardy means that there’s a reasonable expectation that residents would die or become seriously injured or impaired if adverse circumstances persist.8
  • Nursing homes can still receive Medicare and Medicaid funding for as long as six months after an immediate jeopardy finding if it’s in the best interest of residents to stay put (like if there are no good alternatives). The facility must repay funds received during this period if it doesn’t correct its deficiencies during an approved timetable.
  • If a survey reveals deficiencies but they’re not immediate jeopardy, the nursing home has up to six months to undertake corrective action.
  • Civil money penalties (CMPs) can be imposed, with the range for immediate jeopardy being $6,525 to $21,393 per deficiency. Penalties range from $107 to $6,417 for deficiencies that caused harm or had the potential to cause more than minimal harm.
  • Part of these CMP funds go back to the states to enhance nursing home care.
  • Nursing homes found persistently deficient on three standard surveys in a row are subject to state monitoring and denial of Medicare and Medicaid payments.

As far as infection control measures, most weren’t immediate jeopardy findings. There was little sense of urgency. Plus, there aren’t many good alternatives, if any, when nursing home residents need to be transferred elsewhere. Beds are in demand across the country. Also, just because a nursing home is subject to denial of payments doesn’t mean these actions actually happen—just that they could.

In short, seemingly strict regulations are in place, but they are not always effective, nor is enforcement. It’s important to research the facilities in your area and visit them in person (if possible) to make sure you’re comfortable with how they do things. Talk with current and former residents and their families for different perspectives. Many nursing homes do provide good care that is equal to or better than what non-medical family members and friends might provide at home.

The Limitations of Rules and Regulations

It’s great to be knowledgeable about the assisted living and nursing home rules in your state. However, just because these rules exist doesn’t mean they offer 100% protection. Some issues include these:

  • New situations: Many facilities were unprepared for COVID-19.
  • Issues that go beyond rules and regulations: Understaffing is one of several chronic problems. A facility could be staffed at the “right” level according to rules and still be stretched thin.
  • Samples vs. all residents: During inspections, teams look at a sample of residents instead of at each and every resident. Sampling makes inspections more expedient but increases the likelihood that violations are missed.
  • Inconsistent rule following: If a facility has just undergone an inspection, it may let its guard down in some areas.
  • Human nature: When an inspection takes place, it’s usually a team effort (versus just one person). A team minimizes the chances of oversight, but there’s always the chance that someone overlooks a violation.
  • Redress of violations: When an inspection uncovers violations, facilities usually have a set period of time to address these issues. That period of time might seem too long to some residents/families. Plus, there might not even be penalties, depending on the infraction and its severity.
  • Transparency of rules and regulations: It’s not always easy to find inspections reports or information on violations.

Inspection Surveys

Here’s an overview on surveys done in skilled nursing facilities:

  • No advance notice for a standard survey
  • Standard surveys occur at least once every 15 months
  • An extended survey takes place within two weeks of a standard survey finding that a facility provides substandard quality care
  • Special surveys are permitted within two months of facility ownership, administration, management or director changes to ensure quality of care has not decreased
  • Special surveys are permitted if the Health and Human Services (HHS) Secretary questions the facility’s adherence to federal regulations

A standard survey evaluates a sample of the nursing home’s residents. The sample should closely represent the nursing home’s population regarding severity and type of illness/injury/medical condition.

In an extended survey, the sample size is larger than it is during a standard survey. Extended surveys also review the policies and procedures that led to substandard care. These surveys review in-service training and the various aspects that go into staffing. Consultant contracts can be studied, too.

Cost of Care

Medicare and Medicaid

Medicare covers some skilled nursing facility costs in specific situations. It doesn’t cover custodial nursing home care (one way to look at assisted living). From the Medicare website on skilled nursing facilities:9

Your costs in Original Medicare – You Pay:
  • Days 1–20: $0 for each benefit period.
  • Days 21–100: $176 coinsurance per day of each benefit period.
  • Days 101 and beyond: all costs.

If you are enrolled in Medicaid, the program may pay for some costs starting on day 21 and afterward. It pays much more for skilled nursing care than for assisted living (in all states).

Private Pay

Many nursing home residents are private pay, for example, if they’re past day 100 of their Medicare benefit period. Nursing homes can charge private-pay residents a basic daily rate that covers room and meals, general nursing care, personal care, recreation, medical records, housekeeping and linen. Some homes offer all-inclusive rates that cover additional services such as physician visits, medication, lab tests, and physical, speech or occupational therapy, among other things.10

  • Private-pay rates aren’t regulated. Nursing homes can charge whatever they like, and many increase their rates at least once a year.
  • Nursing homes must give you at least 30 days’ notice of private-pay cost increases.
  • Nursing homes are allowed to collect a private-pay pre-payment/security deposit before you move in, but it can’t be more than three months’ worth.
  • Nursing homes cannot ask for or receive donations to ensure placement.
  • Expect to make full financial disclosure so the nursing home knows how long you’ll be able to private pay and when you should apply for Medicaid. The nursing home will help you apply.
  • If the home doesn’t accept Medicaid, you may have to move at some point. Check with your state; New York doesn’t permit residents to be moved out of a nursing home for using up their resources. However, transfer and discharge are OK if residents don’t pay for their stay (through Medicaid or other means).
  • The nursing home can take over your finances and Social Security checks only if you are not able to and cannot find anyone willing to do so.

Spousal protection rules apply to Medicaid recipients (addressed in this assisted living section).

Long-Term Care Insurance Policies

  • State laws vary as to whether certain long-term care insurance policies are legal in the state.
  • States such as New York allow Medicaid asset workarounds (partnership long-term care policies) to combine long-term care private insurance and Medicaid coverage.

Nursing Home Search Tools by State

Medicare Compare and Nursing Home Inspect are good tools to get an idea of how nursing homes stack up against one another. Remember that you can read survey reports themselves when you click on a nursing home in Medicare Compare.

It’s also useful to touch base with your local long-term care ombudsman and to check out your state’s nursing home websites. Check out these links:

State-by-State Nursing Home Resources

Alaska

Arizona

California

Hawaii

Indiana

Iowa

Kansas

Kentucky

Massachusetts

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

South Dakota

Tennessee

Utah

West Virginia

Regulations definitely help assisted living and skilled nursing facilities offer at least a minimum standard of quality care. If these regulations weren’t in place, quality would be all over the place, and facilities would be a lot harder to research.

Obviously, these regulations don’t guarantee 100% safe experiences. Make sure you read all disclosure documents and contracts carefully to understand the facility’s responsibilities and the charges you must pay. Review the Medicare, Medicaid, SSI and long-term care insurance rules (if applicable) in your state.

Visit facilities in person if COVID-19 regulations allow. Ask previous and current residents (and their families) about the living conditions. Conduct a few surprise drop-ins, eat at least one meal at the property, and check for odors and cleanliness. Inspect windows and corners for dust and dirt. Survey the property for safety equipment such as grab bars. Talk with staffers and managers to see whether they are friendly and professional. Ask about medication management, personal care options and staffing at night. Participate in a few social and recreational activities, and check out the outdoor areas, too.

Additional Resources

National Consumer Voice for Quality Long-Term Care: Specialized Information for Nursing Home and Assisted Living Residents

Contact Your State with Questions: Medicare.gov

Coronavirus Information for Nursing Homes: CMS Guidance and Other Resources

Long-Term Services and Supports: FAQs

Medicare Coverage of Skilled Nursing Facility Care: What You Pay and Other Issues

Information for Nursing Home Residents, Family Members, and Care Givers: Resident Rights, Complaints and Other Topics

References and Footnotes

  1. US National Median Long Term Care Support Services Costs. (16 October 2019). PDF. Genworth. Retrieved September 03, 2020, from https://www.multivu.com/players/English/8625551-8625551-genworth-cost-of-care-survey-2019/image/2019CostofCareChart_1571070745075-HR.jpg
  2. Medicare Coverage of Skilled Nursing Facility Care. (Revised July 2019). PDF. U.S. Department of Health and Human Services. Retrieved September 03, 2020, from https://www.medicare.gov/Pubs/pdf/10153-Medicare-Skilled-Nursing-Facility-Care.pdf
  3. Supplemental Security Income (SSI) Benefits. (2020). Social Security Administration. Retrieved September 03, 2020, from https://www.ssa.gov/ssi/text-benefits-ussi.htm
  4. Dorsey, M. (06 August 2020). Common Myths and Mistakes in Medicaid Planning: Pitfalls to Avoid in Developing Your Plan. Saratoga Today. Retrieved September 03, 2020, from https://saratogatodaynewspaper.com/today-in-saratoga/business/item/12109-common-myths-and-mistakes-in-medicaid-planning-pitfalls-to-avoid-in-developing-your-plan
  5. Residents’ Rights. (n.d.). The National Long-Term Care Ombudsman Resource Center. Retrieved September 03, 2020, from https://ltcombudsman.org/issues/residents-rights
  6. What’s a Care Plan in a Nursing Home? (n.d.) Medicare.gov. Retrieved September 03, 2020, from https://www.medicare.gov/what-medicare-covers/what-part-a-covers/whats-a-care-plan-in-a-nursing-home
  7. Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic. (20 May 2020). U.S. Government Accountability Office. Retrieved September 03, 2020, from https://www.gao.gov/products/GAO-20-576R
  8. Appendix Q – Core Guidelines for Determining Immediate Jeopardy. (06 March 2019). PDF. Centers for Medicare and Medicaid Services. Retrieved September 03, 2020, from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_q_immedjeopardy.pdf
  9. Skilled Nursing Facility (SNF) Care. (n.d.). Medicare.gov. Retrieved September 03, 2020, from https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care
  10. Section I: General Information About Nursing Homes – Selecting a Nursing Home in New York State. (Revised August 2017). New York State Department of Health. Retrieved September 03, 2020, from https://www.health.ny.gov/facilities/nursing/select_nh/select_nh.htm