Nursing Home Abuse and Neglect Lawyers

What Is a Nursing Home?

A nursing home is a licensed facility that provides 24-hour nursing care, supervision, help with daily activities, and rehabilitation to people who cannot safely live on their own. Federal law uses two names. A skilled nursing facility (SNF) is a nursing home certified to participate in Medicare (42 U.S.C. 1395i-3). A nursing facility (NF) is a nursing home certified to participate in Medicaid (42 U.S.C. 1396r). Most buildings are both. In CMS's October 2026 data, 13,904 of the 14,686 certified nursing homes were dually certified, 537 were Medicare-only, and 245 were Medicaid-only (CMS Provider Information data, October 2026). Because the two programs share one set of federal requirements, most people use "nursing home," "skilled nursing facility," "nursing and rehabilitation center," "care center," and "health care center" interchangeably. The sign out front does not change the rules.

Short-Stay and Long-Stay Residents

Nursing homes serve two groups that often share the same hallways but have very different needs.

• Short-stay (post-acute) patients arrive from a hospital after surgery, a stroke, a fracture, or a serious infection. They are usually there for rehabilitation, wound care, IV antibiotics, or nursing care while they recover. Medicare Part A pays for much of this care, for up to 100 days per benefit period, if strict conditions are met (Medicare.gov).
• Long-stay residents live in the nursing home, often for the rest of their lives. Most have several chronic conditions, many have dementia, and most need help with bathing, dressing, eating, toileting, and moving. Medicare does not pay for this long-term custodial care. Medicaid is the primary payer for most long-stay residents (KFF).

The distinction matters in a case. A short-stay patient who develops a pressure injury or a urinary tract infection during rehabilitation, and a long-stay resident who loses 15 pounds over three months, have each been harmed by a failure of the same federal duties, but the records, the staffing, and the payment incentives behind those failures are different.

What Nursing Homes Must Provide

Every certified nursing home must provide, or arrange for, the services each resident needs to "attain or maintain the highest practicable physical, mental, and psychosocial well-being" (42 CFR 483.25). In practice, that includes:

• A comprehensive assessment and an individualized, written care plan for each resident (42 CFR 483.21)
• Sufficient nursing staff with the competencies and skills to meet each resident's needs, 24 hours a day (42 CFR 483.35)
• Physician oversight, pharmacy services, and drug regimen review (42 CFR 483.45)
• Food and nutrition services, hydration, and assistance with eating
• Prevention and treatment of pressure injuries, falls, infections, and other avoidable harm
• An infection prevention and control program (42 CFR 483.80)
• Freedom from abuse, neglect, misappropriation of property, and exploitation (42 CFR 483.12)

How Nursing Homes Differ From Other Care Settings

Families often hear "nursing home," "assisted living," and "memory care" used as if they were the same. They are not. The difference controls which rules apply, what records exist, and how a case is built.

Our firm handles cases in each of these settings. See our pages on assisted living facilities, memory care facilities, and group homes and intermediate care facilities. This page focuses on nursing homes.

Nursing Homes by the Numbers

The figures below come mainly from the federal government's own data. CMS publishes a monthly file on every certified nursing home in the country (CMS Provider Information data, October 2026) and, since 2024, a file that groups those homes into chains and reports how each chain performs (CMS Nursing Home Chain Performance data, October 2026). We downloaded both in October 2026 and calculated the totals ourselves. Where a figure comes from another source, it is identified.

Sources: CMS Provider Information data, October 2026; CMS Nursing Home Chain Performance data, October 2026; CMS National Health Expenditure Accounts, Table 15; U.S. Bureau of Labor Statistics, All Employees, Skilled Nursing Care Facilities. Star ratings and abuse icons are point-in-time measures that CMS updates monthly.

How Many Nursing Homes Are There?

There are 14,686 Medicare- or Medicaid-certified nursing homes in the United States as of October 2026 (CMS Provider Information data, October 2026). That number has been drifting down for years. KFF reports that the number of nursing facility residents fell about 10% over the last decade, to about 1.2 million in July 2024, as more care moved to home and community-based settings and to assisted living (KFF). A small number of nursing homes are licensed by a state but not certified by Medicare or Medicaid. Those private-pay-only homes do not appear in CMS data and are not subject to federal inspections.

How Many Nursing Home Beds Are There?

Certified nursing homes have 1,567,009 beds, an average of about 107 beds per facility. On an average day about 1.25 million of those beds are filled, for an occupancy rate of about 80% (CMS Provider Information data, October 2026). Empty beds are not evenly spread. Some rural homes and older urban buildings run well below 80%, while high-performing or well-located homes run near capacity.

Where Are the Nursing Homes?

Nursing homes are concentrated in the most populous states and in the Midwest, where nursing home use has historically been high. Ohio, where our firm is headquartered, has the third-largest number of certified nursing homes in the country.

Source: CMS Provider Information data, October 2026. The full state-by-state count appears in the state complaint table below.

Who Lives in Nursing Homes?

About 1.2 million people live in a certified nursing home on any given day (KFF; CMS Provider Information data, October 2026). Many more pass through each year. MedPAC reports about 1.5 million Medicare-covered skilled nursing stays in 2024, involving about 1.1 million traditional Medicare beneficiaries (MedPAC, March 2026). Short-stay patients turn over quickly. Long-stay residents may live in the same building for years.

Nursing home residents are, as a group, the frailest people in American health care.

• Most are very old. The majority of long-stay residents are 75 or older, and a large share are 85 or older. Women outnumber men, largely because women live longer.
• Many have dementia. Alzheimer's disease and other dementias are among the most common diagnoses in nursing homes. Residents with dementia may be unable to call for help, report pain, or explain how they were injured.
• Most need hands-on help. Long-stay residents typically need staff assistance with several activities of daily living, such as transferring from bed to chair, toileting, bathing, and eating.
• Many cannot move on their own. Residents who cannot reposition themselves depend entirely on staff to prevent pressure injuries.
• Many take many medications. Polypharmacy increases the risk of falls, sedation, constipation, and dangerous drug interactions.
• Some are younger. Nursing homes also care for younger adults after strokes, spinal cord injuries, traumatic brain injuries, and serious mental illness.

These characteristics explain why the federal rules are so detailed and why neglect causes so much harm. A resident who cannot turn, cannot reach water, cannot swallow safely, or cannot press a call light is completely dependent on the staff assigned to them. When staffing is thin, the people who suffer first are the ones least able to speak up. Our article on nursing home abuse and neglect statistics gathers more data on how often harm occurs.

Payer Mix Among Residents

Medicaid is the primary payer for about 63% of nursing home residents, Medicare for about 14%, and private insurance, private pay, and other sources for the remaining 23% (KFF). Many residents enter as private-pay or Medicare patients, use their savings, and then "spend down" to Medicaid eligibility.

How Demand for Nursing Home Care Is Expected to Grow

The number of nursing home residents has declined slightly over the last decade, but the population most likely to need a nursing home is about to grow faster than at any point in American history.

• The 85-and-older population will nearly double by 2035 to about 11.8 million, and nearly triple by 2060 to about 19 million, according to the U.S. Census Bureau (U.S. Census Bureau, P25-1144). People 85 and older are the heaviest users of nursing home care.
• Demand for institutional care could more than triple by 2050. Research summarized by the Peter G. Peterson Foundation projects demand for institutional long-term care rising to about 3.3 times current levels by mid-century (Peterson Foundation).
• Spending is projected to rise to about $337 billion by 2032. CMS actuaries project national spending on nursing care facilities and continuing care retirement communities to reach $337.4 billion in 2032 (McKnight's, reporting CMS projections).
• The Congressional Budget Office has long projected that the aging of the baby boom generation will drive up long-term care spending, with Medicaid bearing much of the cost (CBO).

Three pressures will collide. More people will need nursing home care. The workforce that provides it is already short-staffed, with average nursing staff turnover of about 46% a year (CMS Nursing Home Chain Performance data, October 2026). And Medicaid, the largest payer, is under budget pressure in many states. Those pressures will shape the quality of care, and the number of cases, for years to come.

Who Pays for Nursing Home Care?

Nursing homes are a large business. In 2024, Americans spent $219.9 billion on care in freestanding nursing care facilities and continuing care retirement communities, up 7.3% from the year before (CMS National Health Expenditure Accounts, Table 15; CMS NHE highlights). That figure does not include skilled nursing units inside hospitals, which CMS counts as hospital spending.

Spending by Payer Source

Source: CMS National Health Expenditure Accounts, Table 15, Nursing Care Facilities and Continuing Care Retirement Communities Expenditures, 2024. Figures are rounded.

How Spending Has Grown

Sources: CMS National Health Expenditure Accounts; projection from CMS actuaries as reported by McKnight's.

Medicaid

Medicaid is the largest single payer of nursing home care. Nursing facility services are a mandatory Medicaid benefit for eligible adults 21 and older, which means every state must cover them (Medicaid.gov; Medicaid.gov, Nursing Facilities). Medicaid pays for long-term custodial care, not just short-term rehabilitation, and it is the primary payer for about 63% of residents (KFF). Each state sets its own Medicaid rates. Nursing homes often say Medicaid rates do not cover the full cost of care, and MedPAC reports that the industry's all-payer margin was only about 2.1% in 2024 (MedPAC). Those reported margins do not capture profits paid to related companies, discussed in the ownership section below.

Medicare

Medicare Part A pays for short-term skilled nursing and rehabilitation after a qualifying hospital stay. To qualify, a patient generally must have been admitted to a hospital as an inpatient for at least three consecutive days, must enter the skilled nursing facility within about 30 days of leaving the hospital, and must need daily skilled care (Medicare.gov). Time spent "under observation" in a hospital does not count toward the three days. Medicare covers days 1 through 20 in full, charges a daily coinsurance for days 21 through 100 ($217 per day in 2026), and pays nothing after day 100 in a benefit period (CMS). Medicare does not cover long-term custodial care.

Medicare is the most profitable payer for most nursing homes. MedPAC reports that traditional Medicare margins for freestanding skilled nursing facilities were about 24% in 2024 and are projected to reach about 25% in 2026, and it has recommended that Congress cut Medicare's skilled nursing rates (MedPAC, March 2026). Traditional Medicare spent about $31 billion on skilled nursing care in 2024 (MedPAC). Medicare Advantage plans pay for a growing share of short-stay care under separately negotiated rates.

The gap between Medicare and Medicaid rates creates incentives. Facilities compete for short-stay Medicare patients, and federal enforcement actions have repeatedly alleged that some companies billed for therapy that patients did not need in order to reach higher Medicare payment levels. Several of the settlements described in the chain table below involved those allegations.

Private Pay, Long-Term Care Insurance, and Other Sources

Residents and families paid about $48.7 billion out of pocket in 2024, more than Medicare (CMS NHE). The national median cost of nursing home care in 2025 was about $315 per day for a semi-private room and about $355 per day for a private room (CareScout 2025 Cost of Care Survey). In Ohio the median annual cost of a private room was about $124,666 (CareScout).

Source: CareScout Cost of Care Survey, 2025.

Private health insurance, including long-term care insurance, paid about $19.3 billion. The Department of Veterans Affairs and other government programs paid most of the remainder (CMS NHE).

Why the Money Matters in a Neglect Case

Labor is the largest cost in a nursing home, and nursing staff are the people who turn residents, help them eat and drink, answer call lights, and notice changes in condition. When a facility or its owner decides how much to spend on staff, it is deciding how much care residents will actually receive. Following the money, including payments to related companies that own the building or manage the facility, is often central to understanding why neglect happened and who is responsible for it. Our article on profit-driven short staffing explains this in more detail.

Who Owns Nursing Homes? From Charities to Wall Street

About 74% of certified nursing homes are operated for profit, about 19% are nonprofit, and about 6% are run by government (CMS Provider Information data, October 2026). That balance is the product of six decades of change in how nursing homes are financed, owned, and run. Understanding that history helps explain why ownership is often at the center of a modern nursing home case.

Sources for this table are cited in the discussion that follows.

Medicare, Medicaid, and the First Chains

Before 1965, care for frail older adults was provided mostly in county poor farms, religious and charitable homes, and small family-run boarding homes. The creation of Medicare and Medicaid in 1965 gave nursing homes a reliable stream of public money, and for-profit operators expanded quickly to capture it (Public Policy & Aging Report, Who Owns This Nursing Home?). Some of those operators became publicly traded chains. Beverly Enterprises, which for many years was the country's largest nursing home company, was publicly traded until it was taken private in 2006 (Talk Business & Politics). Manor Care, Vencor (later Kindred), Sun Healthcare, Integrated Health Services, Mariner, and Genesis were also public companies.

So investor ownership of nursing homes is not new. What is new is the form it takes, the speed with which homes change hands, and the number of separate companies that may share in a single facility's revenue.

The 1999 to 2000 Bankruptcies

The Balanced Budget Act of 1997 replaced Medicare's cost-based payment for skilled nursing facilities with a fixed, per-day prospective payment system. Several large public chains that had grown through debt-financed acquisitions could not adjust. By 2000, five of the seven largest nursing home operators, including Vencor, Sun Healthcare, Genesis, Mariner, and Integrated Health Services, were in bankruptcy protection. Only Beverly Enterprises and Manor Care remained solvent (HHS Office of the Assistant Secretary for Planning and Evaluation; American Bankruptcy Institute). The response was a wave of corporate restructuring. Chains sold real estate, divided single companies into many single-facility limited liability companies, and separated the entity that owns the building from the entity that holds the operating license. A longitudinal study of one large chain after its 2006 private equity acquisition found that the new owners added corporate layers and separate limited liability companies, a structure the authors connected to limiting liability exposure (Inquiry, 2017).

The Private Equity Wave

Private equity firms began buying nursing home chains in earnest in the early 2000s. The Government Accountability Office found that private investment firms acquired 1,876 nursing homes between 1998 and 2008, and that 10 firms accounted for about 89% of those acquisitions (GAO-10-710; GAO-11-571). Two deals defined the era:

• Manor Care. The Carlyle Group acquired Manor Care, then the second-largest nursing home company, in 2007 in a deal valued at about $6.3 billion (The Carlyle Group). Manor Care's real estate was later sold to a REIT and leased back. HCR ManorCare filed for bankruptcy in 2018 with about $7.1 billion in debt (Reuters).
• Genesis. Formation Capital and JER Partners took Genesis HealthCare private in 2007 (Genesis HealthCare). Genesis later returned to the public markets through a merger, was delisted, and filed for Chapter 11 bankruptcy in July 2025 (Healthcare Dive).

A widely cited 2007 New York Times investigation reported that staffing fell and deficiencies rose at many homes after private investment groups bought them, prompting Senator Charles Grassley to seek a federal review of private equity ownership (Senate Finance Committee).

What the Research Shows About Private Equity Ownership

The most rigorous study of private equity ownership of nursing homes, by economists at the University of Pennsylvania, NYU, the University of Chicago, and the University of North Carolina, examined about 1,674 homes acquired in 128 private equity deals from 2000 to 2017. It found that private equity ownership increased the short-term mortality of Medicare residents by about 11%, which the authors estimated as about 20,150 additional deaths over 12 years. It also found declines in front-line nurse staffing and increases in antipsychotic use (NBER Working Paper 28474; Review of Financial Studies, 2024). A 2025 systematic review of the research generally found that private equity ownership was associated with higher costs and mixed or worse quality (Health Policy, 2025).

The true extent of private equity ownership is still not fully known. The GAO estimated that about 5% of nursing homes had private equity ownership in 2022, but warned that CMS data alone could not reliably identify private equity ownership because the data often did not list all owners and did not provide a way to identify private equity firms (GAO-23-106163).

REITs, Sale-Leasebacks, and Related Parties

Today's typical chain-affiliated nursing home is not owned by one company. A common structure looks like this:

• An operating company, usually a single-facility LLC, holds the license and employs the staff.
• A property company, often a REIT or an affiliate of the owners, owns the building and collects rent.
• A management company provides administration, policies, and "consulting" for a fee.
• Affiliated companies may provide therapy, staffing, pharmacy, supplies, or insurance.
• One or more holding companies or investors sit above all of them.

Payments to related companies can be substantial. Research by economists at UCLA and the University of Southern California studied Illinois facilities from 2000 to 2021 and found that 77% began doing business with related parties for real estate or management services. They estimated that about 63% of nursing home profits in 2019 were hidden by shifting them to related parties through inflated prices, enough to fund a 29% increase in registered nurses (UCLA Anderson Review; NBER Working Paper 32258). When a facility reports thin margins while its owners collect rent and fees through affiliates, the reported margin does not tell the whole story. Our article Behind the Facade explains how this structure can leave the facility administrator with limited authority over staffing and budgets.

Publicly Traded Operators Today

Several of today's largest operators are, or are tied to, public companies:

• The Ensign Group (Nasdaq: ENSG) went public in 2007 (Ensign Group annual report). In 2014 it spun its real estate into a separate public REIT, CareTrust REIT. Ensign is now the largest nursing home operator in CMS data, with 344 facilities in 17 states (CMS Nursing Home Chain Performance data, October 2026).
• PACS Group (NYSE: PACS) raised about $450 million in an April 2024 initial public offering. In November 2024 a short seller published a report accusing PACS of billing practices that PACS disputed. PACS later restated certain 2024 results, and it has disclosed investigations by the Department of Justice and the Securities and Exchange Commission and a securities class action. Those matters are allegations, and PACS has not been found liable (PACS Group 2025 Form 10-K; PACS Group Q2 2026 Form 10-Q). PACS reported 2025 revenue of about $5.29 billion (PACS Group earnings release).
• National HealthCare Corporation (NYSE American: NHC), founded in 1971, is one of the oldest publicly traded nursing home operators.
• REITs such as Omega Healthcare Investors, Sabra Health Care REIT, CareTrust REIT, and American Healthcare REIT own thousands of nursing home buildings and lease them to operators (Skilled Nursing News).

Ownership Transparency

Federal law has required nursing homes to disclose their owners since the Affordable Care Act of 2010, but CMS did not publish ownership data in a usable form until 2022. In 2023 CMS issued a rule requiring nursing homes to disclose more information about owners, managing organizations, and whether an owner is a private equity firm or a REIT (CMS fact sheet). In 2024 CMS began publishing chain-level performance data, which this page uses throughout (CMS Nursing Home Chain Performance data, October 2026).

Ownership matters in a lawsuit for a practical reason. The company that holds the license may have few assets of its own. The decisions that caused the harm, such as staffing budgets, may have been made by a management company or parent. Identifying every responsible entity is often what separates a case that compensates a family from one that does not. The 2025 Genesis bankruptcy showed the stakes: families with pending and settled injury and death claims became unsecured creditors in the bankruptcy court (KFF Health News).

The 25 Largest Nursing Home Chains

About 70% of nursing homes belong to a chain (CMS Provider Information data, October 2026). The table below ranks the 25 largest chains by number of facilities in CMS's October 2026 chain performance data and links to our detailed page on each chain (CMS Nursing Home Chain Performance data, October 2026). "Largest" refers only to facility count in that data set. The average rating is CMS's overall star rating averaged across the chain's facilities. "Abuse icons" counts facilities CMS has flagged for abuse citations. Fines are the total dollar amount of fines imposed in the previous three years.

Source: CMS Nursing Home Chain Performance data, October 2026. Facility counts change as homes are bought and sold, and counts reported by companies may differ from CMS data. Settlements described were resolved without any admission of liability unless stated otherwise. For the full list, see our nursing home chains directory and our article on the largest nursing home chains.

What the Chain Data Shows

Chain data lets families and lawyers compare companies, not just buildings. Several patterns stand out in CMS's numbers (CMS Nursing Home Chain Performance data, October 2026):

• Average ratings among the 25 largest chains range from 2.1 to 4.2 stars, against a national average of about 3.0.
• Several chains whose facilities are concentrated in a single state appear near the top of the list, and many of them have below-average ratings.
• The number of facilities flagged for abuse varies widely, from none at Trilogy and Foundations to 32 at Ensign, which also has by far the most facilities.
• Fine totals generally rise with size, but not always. Some mid-sized chains have paid more in fines than much larger ones.

A chain's averages do not determine what happened in a particular building. They can, however, show whether a problem in one facility is part of a pattern, which can matter when deciding whom to sue and what evidence to seek in discovery.

Who Regulates Nursing Homes?

Nursing homes are regulated by an overlapping system of federal and state agencies. The federal government sets the minimum standards for any nursing home that accepts Medicare or Medicaid, which is almost all of them. States inspect those homes on the federal government's behalf and also license them under state law.

The Nursing Home Reform Act of 1987

Modern nursing home regulation began with a 1986 Institute of Medicine report that found widespread neglect and abuse and concluded that the government's regulatory system was not protecting residents (Institute of Medicine, Improving the Quality of Care in Nursing Homes). Congress responded with the Nursing Home Reform Act, part of the Omnibus Budget Reconciliation Act of 1987, often called OBRA '87 (KFF summary of OBRA '87). The law:

• Established a single set of requirements for Medicare skilled nursing facilities and Medicaid nursing facilities (42 U.S.C. 1395i-3; 42 U.S.C. 1396r)
• Required each resident to receive a comprehensive assessment and an individualized care plan
• Created a statutory bill of rights for residents, including the right to be free from abuse and from physical and chemical restraints used for discipline or convenience
• Required training and competency testing for nurse aides and state nurse aide registries
• Required unannounced standard surveys, with a range of penalties for noncompliance

In 2022 the National Academies of Sciences, Engineering, and Medicine concluded that the way the country finances, delivers, and regulates nursing home care is failing residents, and called for stronger oversight, better staffing, and greater transparency of ownership and finances (National Academies, The National Imperative to Improve Nursing Home Quality).

The Federal Requirements: 42 CFR Part 483

CMS implements the statute through the Requirements for Long-Term Care Facilities in 42 CFR Part 483, Subpart B. CMS substantially revised these rules in 2016. Key sections include:

• § 483.10, Resident rights, including dignity, self-determination, privacy, visitation, and the right to be informed and participate in care
• § 483.12, Freedom from abuse, neglect, and exploitation, including screening, training, and reporting duties
• § 483.15, Admission, transfer, and discharge
• § 483.21, Comprehensive person-centered care planning
• § 483.25, Quality of care, covering pressure injuries, falls and accidents, nutrition, hydration, incontinence, pain, and more
• § 483.35, Nursing services
• § 483.45, Pharmacy services, including unnecessary drugs and psychotropic medications
• § 483.70, Administration, including governing body responsibility and arbitration agreements
• § 483.80, Infection control

CMS tells surveyors how to interpret each requirement in Appendix PP of the State Operations Manual, which assigns each requirement an "F-tag" number, such as F600 for abuse and neglect, F686 for pressure injuries, and F689 for accidents and supervision (CMS State Operations Manual, Appendix PP). F-tags appear on every inspection report, and they are often a useful starting point for understanding what went wrong.

The Agencies

Sources: CMS; State Operations Manual, Chapter 7; Administration for Community Living; HHS-OIG.

State survey agencies are usually part of the state health department. In Ohio, for example, the Ohio Department of Health inspects and licenses nursing homes (Ohio Department of Health). Our article on how nursing homes are regulated and inspected in Ohio explains Ohio's system in more detail. The agency in every state is listed in the state table below.

Federal Staffing Standards

Federal law requires a registered nurse on duty at least 8 consecutive hours a day, 7 days a week, a full-time director of nursing, and licensed nurses around the clock, plus "sufficient" staff to meet residents' needs (42 CFR 483.35). In 2024 CMS adopted the first numeric minimum staffing standard, which would have required 3.48 total nurse staffing hours per resident per day and a registered nurse on site 24 hours a day. A federal court in Texas vacated the core requirements in April 2025, Congress barred enforcement until 2034 in the July 2025 budget law, and CMS formally repealed them in an interim final rule published in December 2025 (Federal Register; HHS). The national average is about 3.9 total nurse staffing hours per resident per day, including about 0.7 registered nurse hours (CMS Nursing Home Chain Performance data, October 2026), but averages hide large differences between facilities and between weekdays, nights, and weekends.

Who Works in a Nursing Home

Nursing homes employ about 1.59 million people (BLS via FRED). Understanding who does what helps families know whom to ask and helps explain where care can break down.

Sources: 42 CFR 483.35; 42 CFR 483.70; 42 U.S.C. 1395i-3.

Certified nursing assistants provide most of the direct care in a nursing home, and they are usually the lowest-paid staff in the building. When a facility is short-staffed, aides are the first to feel it, and the work they cannot finish, such as repositioning, toileting, and help with meals, is the work whose absence causes pressure injuries, falls, dehydration, and malnutrition. Our articles on inadequate staff training and caregiver burnout explore these issues.

The administrator and director of nursing run the building, but in a chain-affiliated facility many of the most important decisions, such as staffing budgets, wages, and census targets, may be made by a regional or corporate office. Federal rules make the governing body legally responsible for the facility's operation (42 CFR 483.70).

How Nursing Home Regulation Works

The regulatory system runs on inspections, called surveys, that look for violations, called deficiencies. Deficiencies are rated, and the most serious lead to penalties. Understanding the process helps families read inspection reports and understand what the government's findings do and do not mean.

Standard Surveys

Federal law requires a state survey agency to conduct an unannounced standard survey of every certified nursing home at least every 15 months, with a statewide average of no more than 12 months (42 U.S.C. 1395i-3(g)(2)(A)). A survey team spends several days in the building, observes care, interviews residents, families, and staff, and reviews a sample of medical records. A separate Life Safety Code survey examines fire safety and the physical plant.

In practice, many states have struggled to meet those deadlines. A 2023 Senate Aging Committee report found that about 1 in 9 nursing homes had gone two years or more without a standard survey, and that many state agencies had high surveyor vacancy rates (McKnight's, reporting on the Senate Aging Committee report). KFF found that by mid-2026, about 87% of nursing homes had been surveyed within the previous 15 months (KFF). North Carolina's state auditor found that 68% of the state's nursing home inspections were late (North Carolina Health News).

Complaint Surveys and Facility-Reported Incidents

Anyone can file a complaint with the state survey agency. Facilities must also report certain incidents themselves. CMS requires state agencies to triage each complaint and begin an onsite investigation within set timeframes (State Operations Manual, Chapter 5):

The HHS Office of Inspector General has found that states repeatedly failed to meet those timeframes, including for the most serious complaints (HHS-OIG, 2020; HHS-OIG testimony, 2023).

Deficiencies and the Scope-and-Severity Grid

When surveyors find that a facility failed to meet a requirement, they cite a deficiency under the applicable F-tag and assign it a letter from A to L based on how serious it was (severity) and how many residents it affected or could affect (scope) (State Operations Manual, Chapter 7).

Deficiencies at levels G through L, involving actual harm or immediate jeopardy, are the most serious. Immediate jeopardy means the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death (CMS State Operations Manual, Appendix Q). KFF's analysis of recent inspections found that a large share of nursing homes are cited for at least one deficiency involving actual harm or immediate jeopardy (KFF).

Plans of Correction and Federal Remedies

After a survey, the facility receives a written statement of deficiencies (CMS Form 2567) and must submit a plan of correction. If the problems are serious or not corrected, CMS can impose remedies under 42 CFR Part 488, Subpart F.

Sources: 42 CFR Part 488, Subpart F; 45 CFR Part 102 (2025 inflation-adjusted amounts); State Operations Manual, Chapter 7.

Facilities can challenge deficiencies through informal dispute resolution with the state, independent informal dispute resolution when a fine is imposed, and appeals to the HHS Departmental Appeals Board (State Operations Manual, Chapter 7; 42 CFR Part 488). Fines are often reduced. A facility that waives its right to a hearing automatically receives a 35% reduction in a civil money penalty.

The Special Focus Facility Program

CMS's Special Focus Facility (SFF) program targets a small number of nursing homes with a persistent record of serious problems. SFFs are inspected about every six months instead of every 12 to 15 months. A facility graduates after two consecutive standard surveys with no more than 12 deficiencies at level E or below, and can be terminated from Medicare and Medicaid if it fails to improve (CMS SFF program list). In October 2026, 87 nursing homes were SFFs and 440 more were SFF candidates (CMS Provider Information data, October 2026).

State survey agencies pick each state's SFFs from a candidate list CMS updates monthly, with roughly 5 to 30 candidates per state. In a January 28, 2026 revision of its guidance, CMS told states to weigh a facility's prevalence of falls when choosing among candidates with similar records, replacing the staffing measure it had previously used as the tiebreaker. The change followed a September 2025 HHS-OIG report finding that nursing homes failed to report 43% of falls that caused a major injury and a hospitalization among Medicare residents (CMS QSO-23-01, revised January 2026). The emphasis on falls matters: as the demonstrative at the top of this page shows, a fall is rarely a one-off accident. It is usually a symptom of a care plan that was never built or never followed.

The program's results are limited. HHS-OIG found that 64% of the nursing homes that graduated from 2013 through 2022 received another serious deficiency within three years. Among those, 38% received an immediate jeopardy citation and 22% an abuse citation (HHS-OIG, OEI-01-23-00050).

Care Compare and the Five-Star Rating System

CMS publishes inspection results, staffing levels, quality measures, penalties, and ownership information for every certified nursing home on Medicare Care Compare. Its Five-Star Quality Rating System assigns each home an overall rating from 1 to 5 stars, based on health inspections, staffing, and quality measures (CMS Five-Star Quality Rating System). Staffing data come from the Payroll-Based Journal, which nursing homes must submit every quarter (CMS PBJ data). CMS also places a red "abuse icon" on homes cited for abuse within the past year or for repeated abuse over two years. In October 2026, 1,401 homes had the icon (CMS Provider Information data, October 2026).

Star ratings are useful, but they have limits. Quality measures are partly self-reported, inspections occur infrequently, and a facility can have a good rating and still neglect an individual resident.

Mandatory Reporting of Abuse and Crimes

Nursing homes must report alleged abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of property to the administrator and the state survey agency immediately: within 2 hours if the allegation involves abuse or results in serious bodily injury, and within 24 hours otherwise. They must investigate and report the results within 5 working days (42 CFR 483.12(c)). Under section 1150B of the Social Security Act, added by the Elder Justice Act, covered individuals in nursing homes must also report a reasonable suspicion of a crime against a resident to the state survey agency and local law enforcement, within 2 hours if there is serious bodily injury and within 24 hours otherwise (Social Security Act § 1150B; CMS guidance).

Reporting does not always happen. HHS-OIG found that about 1 in 5 high-risk hospital emergency room claims for Medicare beneficiaries living in skilled nursing facilities in 2016 were the result of potential abuse or neglect, and that facilities failed to report many of those incidents to the state survey agency (HHS-OIG, 2019).

How to Read a Nursing Home Inspection Report

A nursing home inspection report, called a Statement of Deficiencies (CMS Form 2567), is one of the most useful public documents about a facility. Reports for the last several years are available on Care Compare, and facilities must make their most recent report available to residents and visitors.

Each deficiency in the report includes:

• The F-tag and the requirement it relates to, such as F686 for pressure injuries or F689 for accidents and supervision (Appendix PP)
• The scope and severity letter from A to L, which tells you how serious the surveyors considered the problem and how many residents it affected
• The surveyors' findings, usually with anonymized resident identifiers, record reviews, observations, and staff interviews
• The facility's plan of correction, which describes what the facility says it did to fix the problem

When reading a report, pay attention to the findings narrative more than the letter grade. The narrative often describes what staff said, what records showed, and how long a problem went unaddressed. Look for repeated F-tags across several inspections, which can show a pattern rather than an isolated mistake. And remember that the report reflects only the residents and records surveyors sampled during a short visit.

A plan of correction is not an admission of wrongdoing, and facilities often state that they submit it only because the law requires them to. In a lawsuit, however, the plan of correction can show what the facility itself believed it needed to change.

A Short Timeline of Nursing Home Regulation and Finance

Nursing home rules have changed in response to scandals, research, and shifts in how care is paid for. The timeline below summarizes the most important changes discussed on this page.

Sources: Institute of Medicine (1986); KFF; HHS-ASPE; CMS; CMS; CMS; CMS PDPM; Talevski; Federal Register; Healthcare Dive.

How Medicare Pays Nursing Homes Today

Since October 2019, Medicare has paid skilled nursing facilities under the Patient Driven Payment Model (PDPM), which sets a daily rate based on each patient's diagnoses, functional status, and clinical needs rather than on the number of therapy minutes provided (CMS). The rates depend on information the facility reports in the Minimum Data Set (MDS), a standardized assessment every certified nursing home must complete for each resident (CMS RAI Manual). Because payment depends on what the facility reports, MDS coding is an area of frequent federal scrutiny, and MDS assessments are important evidence in a neglect case. The MDS records, for example, whether a resident was assessed as at risk for pressure injuries or falls, what help the resident needs to eat or move, and whether the resident lost weight.

How Regulation Differs From a Civil Lawsuit

Families are often surprised to learn that a state investigation, even one that confirms what happened, does not lead to compensation. Regulation and civil litigation are separate systems with different purposes.

Why a Citation Is Not the End of the Story

A substantiated complaint or a deficiency citation can be important evidence, but it is not a lawsuit and it does not decide one. A survey might find a violation at level D, while the full medical record shows the resident suffered a stage 4 pressure injury that caused sepsis and death. A survey might find no deficiency because the surveyors reviewed a different sample of records, the facility's charting was incomplete, or the investigation took place weeks after the event. Survey findings are also sometimes reduced or withdrawn in informal dispute resolution. The absence of a citation does not mean the care was adequate.

Many states limit how survey reports can be used in court, and the rules vary. Whether a regulatory finding is admissible is decided case by case. Federal regulations and state licensing rules are often used to help establish the standard of care, even when they do not create a separate right to sue.

Can You Sue Under the Federal Nursing Home Rules?

Most nursing home cases are brought under state law, usually as claims for negligence, medical negligence, wrongful death, and violations of state residents' rights statutes. In Health and Hospital Corp. of Marion County v. Talevski (2023), the U.S. Supreme Court held 7 to 2 that the Federal Nursing Home Reform Act's rights concerning chemical restraints and transfers and discharges can be enforced through a federal civil rights lawsuit under 42 U.S.C. 1983. That remedy applies only against government-operated nursing homes, such as county homes, and does not apply to most privately owned facilities. Many states also have their own nursing home residents' rights laws that allow residents to sue for violations.

Why Both Systems Matter

Filing a complaint can protect other residents by bringing in state investigators quickly. A lawsuit can uncover what a few days of inspection cannot, including staffing records, internal communications, and budget decisions made by companies far from the facility. Our article on the role of state inspections in nursing home safety explains how inspection findings can be used. If you are considering a case, our article on how to file a lawsuit for nursing home abuse and neglect explains the process.

Types of Nursing Home Neglect and Abuse Cases

Most nursing home cases involve neglect, the failure to provide care that the resident needed and the facility promised. Some involve abuse. The case types below are the ones we handle most often in nursing homes. Each links to a detailed page. Each also lists the federal survey tag (F-tag) inspectors use to cite the related requirement, which can help you search a facility's inspection reports on Care Compare.

For a broader overview, see our articles on nursing home abuse, neglect, residents' rights, and negligence and unexplained injuries.

Warning Signs of Nursing Home Neglect and Abuse

Families are often the first to notice that something is wrong. These signs do not always mean neglect, but they should prompt questions:

• New or worsening wounds, especially on the tailbone, hips, or heels
• Unexplained bruises, fractures, or injuries, or explanations that do not fit the injury
• Sudden weight loss, dry mouth, dark urine, or a resident who seems hungry or thirsty
• Sudden confusion, sleepiness, or withdrawal, which can signal infection, dehydration, or overmedication
• Soiled clothing or bedding, strong odors, or poor hygiene
• Abdominal swelling, vomiting, or no bowel movement for several days
• Repeated falls or hospital transfers
• Call lights that go unanswered, or residents left in bed or in a wheelchair for long periods
• Fear of a particular caregiver, or reluctance to speak in front of staff
• Staff who cannot answer basic questions or who discourage visits

Read more in our article on the most common signs of nursing home abuse and neglect.

What to Do if You Suspect Neglect or Abuse

1. Get help for your loved one. If a resident is in immediate danger, call 911. Ask that the resident be evaluated at a hospital if their condition has changed.
2. Report it. Tell the facility administrator and director of nursing in writing. File a complaint with the state survey agency listed below. For a suspected crime, call the police.
3. Contact the ombudsman. Every state has a long-term care ombudsman program that advocates for residents (ACL). You can find your local ombudsman through the Consumer Voice locator or the Eldercare Locator at 1-800-677-1116.
4. Document what you see. Take dated photographs, write down names, dates, and what you were told, and keep copies of any messages.
5. Request records. Residents and their legal representatives have the right to access the resident's records (42 CFR 483.10(g)).
6. Talk to a lawyer before signing anything. Facilities sometimes ask families to sign releases or arbitration agreements after an incident.

Facilities cannot retaliate against residents or families for filing a complaint (42 CFR 483.10). See our article on protection against retaliation.

How to Evaluate a Nursing Home

Whether you are choosing a nursing home or worried about the one your loved one already lives in, public data can tell you a great deal. Here is how to use it.

Start With Care Compare

Search the facility on Medicare Care Compare. Look past the overall star rating to the separate ratings for health inspections, staffing, and quality measures. Check whether the facility has an abuse icon, whether it is a Special Focus Facility or candidate, and whether it has paid fines or had Medicare payments denied in the last three years. Then open the inspection reports and read the actual deficiencies, not just the counts (Medicare.gov, inspection results).

Look at Staffing, Not Just Ratings

Staffing is the single most important thing to understand about a nursing home. Care Compare reports total nurse staffing hours per resident per day, registered nurse hours, weekend staffing, and staff turnover, all drawn from Payroll-Based Journal data (CMS PBJ). Compare the facility to the national average of about 3.9 total nurse hours and 0.7 RN hours per resident per day, and to the national average turnover of about 46% (CMS Nursing Home Chain Performance data, October 2026). Low weekend staffing and high turnover are warning signs even when weekday staffing looks adequate.

Find Out Who Owns It

Care Compare lists the facility's owners and managing organizations, and CMS's chain data show how the facility's chain performs nationally (CMS Nursing Home Chain Performance data, October 2026). If the facility belongs to one of the largest chains, our nursing home chain pages summarize the chain's size, ratings, penalties, and history. Ask the facility whether it has changed hands recently. A change of ownership can bring changes in staffing and management.

Visit, and Visit Again

Visit at different times of day, including evenings and weekends, when staffing is often thinnest. Watch how long call lights stay on, whether residents are up and dressed, whether staff help residents eat and drink, and how staff speak to residents. Ask how many residents each aide is assigned on each shift, who the director of nursing is and how long they have been there, and whether the facility uses agency staff. Ask to see the most recent inspection report, which the facility must make available (42 CFR 483.10).

Questions to Ask Before Admission

• How many residents is each nurse aide responsible for on day, evening, and night shifts, and on weekends?
• How often is a registered nurse in the building, and who covers nights?
• How do you prevent pressure injuries and falls, and how will you tell me if my loved one's condition changes?
• How will you meet my loved one's diet, swallowing, and fluid needs?
• How do you handle residents with dementia who wander or become agitated? Do you use antipsychotic medications?
• Will I be asked to sign an arbitration agreement? (You do not have to sign one to be admitted.)
• Who owns the facility and the building, and has ownership changed in the last three years?

More: family visitation rights and the legal rights of seniors living in nursing homes.

How to File a Nursing Home Complaint in Every State

Each state has a survey agency that inspects nursing homes for CMS and investigates complaints, usually within the state health department. The table below lists the agency for all 50 states and the District of Columbia, a link to its complaint page, its complaint phone number, and the number of certified nursing homes and beds in the state. You can file a complaint whether or not you plan to bring a lawsuit, and you can usually file anonymously.

Sources: CMS State Survey Agency contact directory, with complaint links updated from each state agency's website (checked October 2026); facility and bed counts from CMS Provider Information data, October 2026. Agencies change their websites often. If a link does not work, call the number listed, or see Medicare.gov, Filing a complaint.

Tips for Filing an Effective Complaint

• Identify the resident, the facility, and the dates as specifically as you can.
• Describe what happened, what you observed, and who you told. Attach photographs if the agency allows it.
• Say whether the resident is still at risk. That affects how quickly the state must respond.
• Ask for a complaint number and follow up. You can ask the agency for the results of its investigation.
• Look up the facility's inspection history on Care Compare to see whether similar problems have been cited before.

Other places to report include the long-term care ombudsman (Consumer Voice ombudsman locator), Adult Protective Services, your state's Medicaid Fraud Control Unit (HHS-OIG MFCU directory), and the police. See our guide on how to identify and report elder abuse.

Nursing Home Residents' Legal Rights

Federal law gives every resident of a certified nursing home a set of enforceable rights (42 CFR 483.10). They include the right to:

• Be treated with dignity and respect, and be free from abuse, neglect, and exploitation
• Be free from physical and chemical restraints used for discipline or convenience
• Be fully informed about their care and participate in care planning
• Refuse treatment
• Access their medical records
• Receive visitors, communicate privately, and voice grievances without fear of retaliation
• Manage their own money, or have it managed and accounted for properly
• Remain in the facility unless a transfer or discharge meets federal requirements, with written notice and the right to appeal (42 CFR 483.15)

Many states add their own residents' rights statutes. More: legal rights of nursing home residents and illegal nursing home discharges.

Arbitration Agreements

Many nursing homes ask residents or families to sign a pre-dispute arbitration agreement at admission, which would require any future claim to be decided by a private arbitrator rather than a jury. CMS banned these agreements in 2016, but a federal court blocked the ban (American Health Care Ass'n v. Burwell). Under the rule CMS adopted in 2019, facilities may offer arbitration agreements, but they may not require one as a condition of admission or continued care, must explain the agreement in a way the resident understands, and must give the resident 30 calendar days to rescind it (CMS; 42 CFR 483.70). If you were asked to sign one, it may still be possible to challenge it. See what families should know about arbitration agreements.

Time Limits to File a Lawsuit

Every state sets a deadline, called a statute of limitations, for filing a nursing home claim. Deadlines vary by state and by type of claim, and some are short. In Ohio, many claims against nursing homes must be filed within one year (Ohio Rev. Code 2305.113), and wrongful death claims generally within two years of death (Ohio Rev. Code 2125.02). Some states also require a pre-suit notice or an expert affidavit. Because of these rules, it is important to talk to a lawyer promptly. See how long you have to file.

Evidence in a Nursing Home Case

Nursing home cases are built on records. Important evidence often includes the resident's complete chart, the MDS assessments and care plans, medication administration records, wound and weight logs, incident reports, staffing schedules and timecards, Payroll-Based Journal data, inspection reports, policies and procedures, and corporate budgets and management agreements. See our guide to essential evidence.

What Happens in a Nursing Home Lawsuit

Every case is different, but most nursing home cases follow a similar path.

1. Free case review. We talk with the family about what happened, the resident's injuries, and the timeline. We ask about the facility, the hospital records, and any death certificate.
2. Records investigation. We gather the nursing home chart, hospital records, inspection history, staffing data, and ownership information. Our paralegal investigators review the records page by page to build a timeline of what the facility knew and when.
3. Expert review. Nurses, physicians, and other experts review the records to evaluate whether the care met accepted standards and whether the failures caused the injury or death. Some states require an expert affidavit or certificate of merit with the complaint.
4. Filing the lawsuit. We file a complaint in the appropriate court against the responsible parties, which may include the licensed facility, its operator, management company, and parent or affiliated companies. You can see examples in our complaint filings.
5. Discovery. Both sides exchange documents and take depositions. In a nursing home case, discovery often focuses on staffing records, policies, training, incident reports, internal communications, and corporate budgets and management agreements.
6. Mediation and settlement discussions. Many cases are resolved through settlement, often after discovery shows how strong the evidence is. A settlement requires the family's agreement.
7. Trial. If the case does not settle, a jury decides whether the defendants are responsible and what damages to award. We prepare every case for trial from the start.

What Damages Can Be Recovered?

Depending on state law and the facts, damages in a nursing home case may include the resident's pain and suffering, medical expenses, and, in a wrongful death case, the family's loss of the resident's companionship, guidance, and support. Some states allow punitive damages when a defendant's conduct was malicious or showed a conscious disregard for residents' safety. Many states cap certain damages, and the caps vary by state and type of claim.

Who Pays a Judgment or Settlement?

Nursing homes typically carry professional and general liability insurance, though limits vary and some operators use affiliated or offshore insurance companies. When the licensed operator has little insurance or few assets, identifying the companies that controlled the facility can be critical. Bankruptcy filings, such as Genesis HealthCare's 2025 Chapter 11 case, can delay or reduce recoveries for families with pending claims (KFF Health News). These are among the reasons we investigate ownership early. See how trial experience affects settlement.

Common Defenses in Nursing Home Cases

Nursing homes and their insurers raise many of the same defenses in case after case. Knowing them helps families understand why careful investigation matters.

• "The injury was unavoidable." Facilities often argue that a pressure injury, fall, or weight loss was an unavoidable result of the resident's age and illnesses. Federal rules treat a pressure injury as unavoidable only if the facility assessed the resident, implemented and monitored appropriate interventions, and revised them when they did not work (Appendix PP). The records usually show whether that happened.
• "The resident would have died anyway." Many residents are seriously ill. The question is whether the neglect caused or hastened the injury or death, or caused suffering that should not have happened. Medical experts address causation directly.
• "We were in compliance." A clean inspection does not mean the care given to one resident met the standard of care, for the reasons explained above.
• "The family agreed to arbitration." Arbitration agreements can sometimes be challenged, for example if the person who signed lacked authority or the agreement did not meet federal requirements.
• "The parent company had nothing to do with it." Corporate defendants often say only the licensed facility is responsible. Evidence about who set the budgets, staffing levels, and policies can show otherwise.
• "The claim was filed too late." Statutes of limitations and pre-suit notice requirements can bar claims, which is why it is important to act promptly.
• "The charting shows the care was provided." Records are sometimes incomplete, contradictory, or created after the fact. Comparing the chart with staffing records, electronic audit trails, and witness accounts can reveal what actually happened.

A Nursing Home Practice Handling Cases Nationwide

Michael Hill Trial Law represents families in nursing home cases nationwide, and the firm has handled more than 1,000 cases. For more than a decade, Michael Hill has dedicated his practice to representing families harmed by abuse, neglect, and wrongful death in nursing homes and other long-term care facilities. Our attorneys are licensed in numerous states, and we work with affiliate firms across the country.

We are a trial law firm. We prepare every case as if it will be tried, because nursing home companies and their insurers evaluate cases based on whether the plaintiff's lawyers are prepared to go to trial. Our trial team, Matt Mooney, Molly Morris, Joe McCoy, Lina Girgis, and DL Rencher, works with paralegal investigators who build each case from the records up, including the corporate and ownership records discussed on this page.

Michael Hill Trial Law has recovered hundreds of millions of dollars for clients in nursing home and institutional neglect cases. Results include:

• A $26 million jury verdict for wrongful death, the highest nursing home verdict in Ohio history
• $12 million, $10 million, $9.95 million, and $8.7 million wrongful death settlements
• $5.8 million, $5 million, $5 million, and $4.4 million wrongful death jury verdicts
• A $4 million settlement for a resident who was physically assaulted and a $3.9 million jury verdict for a permanent deformity
• $2.3 million, $1.5 million, $1.3 million, $1.25 million, and $1 million wrongful death settlements
• A $2 million settlement for a fall injury, a $1.85 million settlement for a brain injury following a fall, and a $1.4 million settlement for a bedsore (pressure injury)

Prior results do not guarantee a similar outcome.

We handle nursing home cases on a contingency fee, with case costs advanced by the firm. Michael Hill has been recognized by Super Lawyers and The National Trial Lawyers. Learn more about our team, our cases in the news, and recent complaint filings. For company-specific information, see our nursing home chain pages.

Glossary of Nursing Home Terms

Nursing Home FAQ

Answers to 70 common questions about nursing homes, regulation, residents' rights, and nursing home cases. Each answer lists its sources. Last reviewed October 28, 2026.

Nursing Home Basics

Costs and Payment

Ownership and Chains

Regulation and Inspections

Complaints and Reporting Abuse

Residents' Rights

Neglect and Injuries

Lawsuits and Legal Process

About Michael Hill Trial Law