Federal & State Nursing Home Laws and Regulations 

Nursing home laws and regulations are put in place to protect the elderly from abuse by their caretakers. Seniors are often an at-risk group for exploitation, including nursing home abuse. To offer protection for people as they age and need assistance, the government regulates the care provided in nursing homes to prevent abuse and neglect. 

At the Nursing Home Law Center, we see the impact of problems like nursing home abuse and how it can devastate a family. We work with families to take legal action and hold nursing homes accountable. Read on to find out why nursing home regulations and laws are essential to protecting anyone who needs the assistance of a nursing home.

Overview of Federal Nursing Home Regulations

Nursing home regulations are covered locally, state, and federally. Several significant pieces of legislation affect all nursing homes and are essential to know. Here are the most critical pieces of federal legislation regarding nursing homes. 

The Nursing Home Reform Act

The Nursing Home Reform Act of 1987 (NHRA) set the groundwork for federal nursing home regulations. It establishes the essential criteria for nursing homes regarding setup and quality of care for residents. The Nursing Home Reform Act also establishes the basis of protection against nursing home abuse and neglect. 

The NHRA requires that all facilities be certified, which is an essential step in ensuring they are appropriately staffed and managed. By requiring certification, every nursing home is monitored by a state-level organization, which makes abuse and neglect much harder to get away with [1].

Personalized Care Plans

Under the NHRA, all nursing home patients must have a personalized care plan, which is the guideline for how they will be cared for in the facility. The nursing home is supposed to work with patients and their representatives to establish a care plan, giving the patient the ability to have input and control over the plan. 

Care plans must be reviewed regularly to determine whether updates or changes are needed. By federal law, that review must happen at most every 90 days. All plans must also be recorded in writing and kept on file with the patient’s medical file for easy access and documentation.  

Nursing Home Inspections and Oversight

A state government agency should monitor and certify nursing homes. The agency certifies that facilities are set up correctly and continue to meet government standards. This often means conducting on-site inspections to review things that affect patients’ quality of life. 

Unfortunately, most states have issues maintaining inspection report schedules since agencies are usually understaffed. Fewer inspections and longer intervals between them make it harder to catch nursing home violations and prevent abuse. 

Nursing Home Resident’s Bill of Rights

Perhaps the most essential part of the NHRA is establishing patients’ rights, including freedom from abuse. Other laws can address this in more detail, but basic protections are in place, making abuse a federal crime and giving victims recourse at the highest level. 

In practice, this often means victims can take legal action against nursing home facilities that abuse or neglect their patients. Personal injury lawyers can file nursing home cases for victims, which can recover compensation to help victims get the care they need to heal.

Alternatively, there are government organizations that can take action against nursing homes to ensure they are held accountable for abuse and neglect. From removing their licenses to filing criminal charges, these organizations work on behalf of victims to ensure that bad actors don’t continue to abuse patients. 

Another important right outlined in the resident’s bill of rights is the right to participate in developing their care plan. Patients must be consulted when plans are designed so they are involved in the process. Because of this, nursing homes cannot ignore them and do whatever they want.  

Safety and Facility Standards 

Since nursing homes are primarily responsible for caring for groups that cannot care for themselves, the NHRA establishes safety and facility standards. This prevents facilities from creating conditions that are medical, mental, and overall care hazards for nursing home patients. These include:

• Fire safety plans
• Building accessibility
• Emergency plans
• Maintenance practices and plans

Facilities are monitored and inspected regularly to reduce the chances of patients being injured by negligence in facility upkeep or management. Unfortunately, this is not always enough to ensure facilities comply with standards. 

Many government agencies that oversee nursing home facilities are chronically understaffed, making it hard to effectively monitor all of the facilities in a given area.

Staffing Requirements 

Each nursing home must have a specific number of staff members for its residents, and the ratio is set based on the type of staff member. For example, facilities are required to have registered nurses on-site at all times [2]. However, they only need enough nurse’s aides to provide about three hours of care per patient daily [3]. 

Because of budget and staffing issues, many facilities operate without meeting these requirements. It is often temporary because nursing home staff needs days off or other time away. Still, it frequently becomes a chronic problem as facilities struggle to find or afford enough staff to maintain compliance with nursing home laws. 

Regulations are in place because staffing levels are needed to meet the minimum level of care for each patient. Initiatives are being taken to address the issue, including improving facility funding and a general recruiting push to increase the number of people in the industry. Recent legislation aims to address the staffing issue so that care facilities have the people necessary. 

Infection Control Policies 

Nursing homes are medical facilities and are prone to the spread of infections within their populations. Like other medical facilities, nursing homes should have infection control policies that rely on sanitation and proactive measures to control contamination. One of the leading signs that a facility has management and maintenance issues is the spread of infections.

Infection control policies combine several methods to address the possible spread of infections. They begin with a quality staff training program. Staff members have the highest chance of spreading diseases through the population because they interact closely with residents. Teaching staff ways to minimize the spread goes a long way toward reducing infections. 

Another essential element of infection control policies is sanitation and medical waste management. Keeping a facility clean can significantly reduce infections. 

Finally, the right precautions can significantly help against the spread of infections. This means having a procedure to handle new patients, recognize infections, and provide appropriate treatment. The quality of the facility’s care largely depends on the practices it has in place to manage possible health issues like infections regularly. 

Quality Assurance and Performance Improvement (QAPI) 

Every nursing facility is required to participate in a QAPI program [4]. The QAPI program is a quality management program designed to ensure that nursing home residents continue to receive high-quality care. The program implements practices that require the facility to continue improving over time or face being shut down. 

Each QAPI program has two components: standards for quality assurance and a systems management program to support continuous performance improvement. The first component focuses on establishing and maintaining a basic quality of care that aligns with the resident’s needs. 

The second component focuses on incorporating industry improvements in health care and patient care with monitoring and reporting on the facility’s processes to improve them over time. When implemented correctly, this component forces nursing homes to improve their quality of care or comply with state laws. 

State-Specific Regulations 

While the federal government has restrictions on nursing homes, so do state-level government organizations. State-level governments often oversee nursing homes in their states, not the federal government. Because of this, many state-specific regulations are in place to address specific issues that have come up in each state. 

For example, federal regulations are a baseline for care and facility management, but states must set up systems for reporting and addressing abuse. States handle much of the implementation of government regulations and have their requirements to better align with state-based legislation. 

In many states, the regulations are designed to strengthen violation penalties. States like California, Massachusetts, New York, Rhode Island, and Florida have significantly stricter regulations and more significant penalties for nursing home violations. In 2024, the average nursing home violation fine cost $34,000 [5]. 

Violation fines can quickly accumulate and threaten a nursing facility’s financial stability, which should be a deterrent. However, many facilities still struggle to meet requirements for various reasons. 

Staffing is a constant problem for nursing homes as they must have a specific number of staff members per patient. Available staffing is challenging for facilities, given that the number of qualified care providers is insufficient in each state. This pushes facilities to work with fewer staff members than are needed while trying to comply with other quality-of-care regulations. 

The Role of the Ombudsman 

An ombudsman is a representative responsible for caring for nursing home patients. In essence, they are the officials you can turn to for help if your facility abuses or neglects you. An ombudsman can investigate a facility to make sure that it adheres to the regulations or take action to fix it. 

Your ombudsman can also advocate for you if you need help dealing with a nursing home facility problem. Reporting an issue to the ombudsman means that he will investigate the facility and take action to fix the issues. 

A nursing home ombudsman can help address various issues impacting a resident’s quality of life, such as nursing home abuse, dental care, or nutritional problems. They can advocate for residents being discharged too early or not receiving appropriate health care. A local ombudsman is often the first line of defense against nursing home abuse.

Impact of Non-Compliance on Nursing Homes 

If skilled nursing facilities fail to comply with government regulations under federal law or state laws, there are severe repercussions for nursing homes and residents. This can include:

• Financial penalties – Failing to comply with federal laws can lead to serious financial consequences. A state or federal agency can assess fines to assisted living facilities that do not comply with state or federal requirements. These agencies can also remove or restrict a skilled nursing facility’s ability to bill under Medicare and Medicaid programs, representing a serious loss in revenue. 
• Loss of certification – Non-compliance from a skilled nursing facility can lead to a loss of its certification, either at the state level or with Medicare and Medicaid services. This can lead to the closure of long-term care facilities. 
• Reputational damage – No one wants to stay in a skilled nursing facility that government agencies and newspapers have reported non-compliant with state and federal regulations. When prospective nursing home residents and their family members look for skilled nursing care, they are unlikely to choose healthcare providers who have developed a bad reputation.
• Legal actions – Non-compliance with federal and state laws can put many residents in harm’s way. In some cases, long-term care facilities have been sued when their lack of compliance injures or kills a nursing home resident or subjects them to elder abuse.

Challenges in Regulatory Compliance 

Skilled nursing facilities sometimes face challenges when trying to meet the federal nursing home regulations outlined in the Nursing Home Reform Act and other standards under federal and state law. Some of the most common challenges nursing homes face when it comes to compliance are: 

Staffing Shortages

Sometimes, nursing homes have difficulties maintaining sufficient staff to provide proper health care to nursing home residents. Most nursing home care staff are underpaid, and the work can be physical and strenuous. As a result, this often leads to staffing shortages. 

Not having sufficient nursing staff is one common risk factor for poor patient care quality. If there aren’t enough staff members to provide services or help with daily living activities, the overall quality of care suffers. 

For example, if there aren’t enough nurses to respond to resident needs, some nursing home residents will have to wait in pain or without treatment until nurses or other staff members can help them. This can quickly put operations and care quality outside of what is allowable under federal requirements.

Staffing shortages also lead to caregiver burnout, impact residents’ quality of life, and put them at risk of elder abuse. In these nursing home environments, it is more likely that residents will develop pressure sores, suffer medication errors, and be subjected to physical restraints simply because there isn’t sufficient nursing staff to provide proper personal care for them.

Budget Constraints

Many nursing homes operate on thin profit margins, with staffing and care costs outpacing what they receive through Medicare and Medicaid services. Because of this, the care provided to nursing home residents can suffer. 

Even a nursing home resident who pays out of pocket for services may face quality of care issues because of the high costs of running a skilled nursing facility. 

Complexities of Nursing Home Administration

Nursing homes are complex due to the many regulations for the healthcare industry. Federal nursing home regulations, along with state and local regulations, create layers of administrative work that make it essential to deliver quality patient care. 

Common Violations and Penalties 

Unfortunately, many long-term care facilities have violations found during inspections that can have severe penalties. Some common regulatory violations identified in nursing homes include:

• Inadequate care – Failing to provide appropriate treatment that meets the standard of care required by regulations and meeting overall medical care standards.
• Improper documentation – Failing to maintain and provide the appropriate documentation required by law.
• Failure to meet staffing requirements – Federal nursing home regulations require a specific ratio of patients to staff, which many facilities cannot maintain because of budget and staffing issues. 
• Short Staffing – Failing to maintain the ratio of staff to patients required by law. 
• Unsafe Conditions – Failing to maintain safe living conditions, including food safety violations, cleanliness issues, maintenance failures, and other problems that can lead to illness or injury. 

Penalties for nursing home abuse violations can vary depending on the situation. However, they follow the same guidelines. For example, a facility that fails to meet staffing requirements may be required to accept new patients only once it can prove that it can meet the requirements for an extended period. 

Repeated violations can result in more significant penalties. One of the most severe penalties affects the facility’s certification, which can be conditional. That certification can be revoked unless the facilities can prove that they corrected the errors that led to repeated violations. 

Since a facility cannot operate without a certification, revoking it means closing operations immediately. 

Facilities facing penalties can also face significant fines. The fine amount depends on the violation, the number of violations, and the severity of the problem. Some penalties start at $1,000 per violation, with others reaching $100,000 per violation. 

Criminal charges can be filed against the specific staff member committing the abuse or the administration of the nursing home if they are complicit. Individual abusers may have their nursing licenses or certifications revoked, and business administrators can be banned from working in a nursing home or the healthcare industry. 

Civil cases can be filed against abusers or their employers to collect compensation from liable parties that can help pay for your recovery expenses. You can file a civil case regardless of whether or not criminal charges are filed. 

That means that regardless of the outcome of the criminal investigation, you can hold the facility accountable. To do this, work with a personal injury lawyer who specializes in nursing home abuse.

Reporting and Addressing Abuse or Neglect

One of the most critical sets of federal nursing home regulations deals with reporting and addressing abuse or neglect. Nursing facility staff is required to document and report abuse or neglect as a means of protecting patients. 

Unfortunately, many facilities do not for several reasons, including protecting their interests. It usually falls to family members to take action on the patient’s behalf, which often takes longer and leads to more abuse. 

While federal nursing home regulations set the base requirements for reporting abuse, they also emphasize individual states’ setting up guidelines and systems for reporting abuse. 

This can be problematic as it creates differences in the reporting requirements, methods, and ways states can respond to abuse. Protection for a nursing home resident can change substantially based on their location. 

Facilities are required to report any physical, emotional, financial, or sexual abuse that is reported. Once the complaint is brought to the attention of the nursing home administrator, it should be reported immediately to the state oversight agency. This initial report is often limited in details or evidence, but the facility can file a follow-up report within the next few days with more information. 

The Role of an Attorney 

If you or your family member has suffered as a result of the care you received in a nursing home, it is important to schedule a consultation with a nursing home neglect attorney to discuss your legal options for moving forward. 

Nursing homes should be held responsible for their actions, and the standard of care should be higher than it currently is. With the help of a legal expert, it is possible to recover compensation for injuries and losses. Most importantly, it is possible to hold a skilled nursing facility accountable for what happened through economic, non-economic, and punitive damages.

During your initial consultation, you’ll discuss what happened and how the non-compliance impacted you or your loved one. Then, a nursing home abuse attorney will assess your case to see if it is possible to move forward with civil action. 

It is essential to schedule a consultation with a lawyer as soon as it is reasonable, as you will want to start the process before the statute of limitations runs out. How much time you have to file a civil nursing home abuse case will depend on the state in which it is filed. This is typically a couple of years from the date of the injury or death.

Your nursing home abuse lawyer will handle the legal process for you. They will help gather evidence to support your case, correctly file the lawsuit with the appropriate court, negotiate with nursing homes and insurance companies, and represent your case in court if necessary. Most civil cases against nursing homes settle out of court and do not go to trial. 

Secure Expert Legal Representation!

Nursing home residents and their families can seek compensation for victims of nursing home abuse or neglect. There are several paths to taking action, including filing a civil action against the facility. Doing so can lead to collecting compensation for expenses like finding another nursing facility and handling other financial affairs. 

If you are considering filing a civil action against a facility, your next step should be to discuss your case with a nursing home abuse and neglect lawyer. The Nursing Home Law Center specializes in nursing home abuse. We work with the victims and their families to collect compensation and hold facilities accountable. 

Fill out our contact form or call toll-free at (800) 926-7565 to schedule a free consultation. 

Resources: [1] Congress; [2] CMS.gov; [3] American Hospital Association; [4] CMS; [5] LTCCC Alert: New Data on Nursing Home Citations and Penalties