Assisted living facilities have zero federal quality oversight, and state inspection rates as low as 25% per year

Unlike nursing homes, assisted living facilities have no federal quality standards, no federal inspection requirements, and no standardized data collection. Over 1 million Americans live in these facilities, many of them increasingly frail and cognitively impaired, but oversight is entirely left to states — and states do it inconsistently at best. Maryland inspected only 25.7% of facilities in one recent year (improved to 55.6% in 2024). A 2018 GAO report found that most state Medicaid agencies did not even track "critical incidents" affecting Medicaid beneficiaries in assisted living. In January 2024, witnesses at a Senate hearing testified that inadequate training, improper communication from operators and state agencies, and limited data collection contribute to subpar conditions. The absence of federal oversight means families have no reliable way to compare facilities. There is no Care Compare equivalent for assisted living. There are no star ratings, no standardized quality metrics, no public inspection reports in most states. A family choosing between two assisted living facilities in different states is comparing entities governed by completely different rules — different staffing requirements, different training mandates, different definitions of what "assisted living" even means (states use terms like "residential care," "adult care home," and "personal care home" interchangeably). A facility that would fail inspection in one state might be fully compliant in another. This regulatory vacuum persists because assisted living was historically positioned as a housing option, not a healthcare setting. The industry lobbied to maintain this distinction precisely because it meant lighter regulation and lower costs. But the resident population has changed dramatically: people entering assisted living today are older, sicker, and more cognitively impaired than the population these facilities were designed to serve. Senators Warren, Gillibrand, and Wyden called for a GAO investigation into state oversight of assisted living in 2024, and proposed federal legislation (the ASSISTED in Assisted Living Act) would have created an advisory council and voluntary reporting — but even that modest bill stalled. The industry's trade groups argue that federal oversight would increase costs and reduce the supply of beds, which may be true but leaves residents in a setting where no one is systematically checking whether they are safe.