Key Findings from 411,456 Citations
- •5.6% of citations are immediate jeopardy violations - life-threatening situations requiring immediate action
- •17.5% involve care planning failures - the #1 cited deficiency category
- •7.7% of citations are for abuse/neglect prevention failures - facilities failing to protect residents
- •26.4% of 1-star facilities have abuse violations vs 0% of 5-star facilities
- •Infection control violations are the most common single deficiency - cited in 12.4% of cases
Understanding Neglect vs. Abuse
Neglect is different from abuse. Abuse involves intentional harm—hitting, yelling, threatening. Neglect is the failure to provide necessary care.
Both are serious. Both harm residents. But neglect is often harder to spot because it's what doesn't happen—the medication not given, the call light not answered, the bath not provided.
Government inspectors track these failures through deficiency citations. Every violation gets documented, categorized, and assigned a severity code. We analyzed 411,456 of these citations to show you what inspectors actually find—and what families should watch for.
The Severity Scale: What Citation Levels Mean
When inspectors find a violation, they assign a severity code from A to L. Understanding this system helps you read inspection reports and know what matters most.
Why This Matters
When researching facilities, check their inspection reports. One or two D-level violations? Common. Multiple F-level violations? Concerning.
Any J-K-L citation? Walk away. Immediate jeopardy means someone's life was in danger.
What Inspectors Actually Find: The Most Common Violations
Based on our analysis of 411,456 citations, here are the top deficiency categories—what they mean and why they matter.
| Rank | Deficiency Category | % of Citations |
|---|---|---|
| 1 | Resident Assessment & Care Planning | 17.5% |
| 2 | Nutrition and Dietary | 17.4% |
| 3 | Quality of Life and Care | 16.1% |
| 4 | Resident Rights | 14.2% |
| 5 | Infection Control | 12.6% |
| 6 | Pharmacy Service | 8.1% |
| 7 | Freedom from Abuse, Neglect, & Exploitation | 7.7% |
The 7 Warning Signs You Can't Ignore
Based on hundreds of thousands of citations, here are the most common signs of neglect—what to look for and why it happens.
1. Incomplete or Ignored Care Plans
What this means: Every resident should have a detailed care plan addressing their specific needs—mobility, nutrition, medications, social activities. When facilities fail to create these plans or don't follow them, residents don't get the care they need.
- Care plan meetings scheduled but repeatedly cancelled or rescheduled
- Staff unable to answer basic questions about your loved one's care routine
- Needs you've discussed (physical therapy, special diet) not being implemented
- Generic care approaches that don't account for individual preferences
- "Can I see mom's current care plan?"
- "When was it last updated?"
- "Who on staff is responsible for implementing each part?"
2. Nutrition and Food Safety Problems
What this means: Facilities must store food safely, serve nutritious meals, and ensure residents eat enough. Citations range from kitchen sanitation issues to residents losing dangerous amounts of weight.
- Unexplained weight loss (clothes fitting looser, sunken cheeks)
- Complaints of hunger or thirst
- Food left untouched (and no one checking why)
- Meals served cold or unappetizing
- Residents needing feeding assistance not receiving it
- Limited food choices or dietary restrictions ignored
Weight loss of more than 5% in a month or 10% in six months without medical explanation is a serious warning sign. Ask to see weight records.
3. Poor Hygiene and Personal Care
What this means: Residents have the right to be clean, groomed, and dressed appropriately. When facilities are understaffed or poorly managed, basic hygiene gets neglected.
- Body odor or unwashed hair
- Dirty or stained clothing
- Overgrown fingernails or toenails
- Men not shaved (if they prefer to be)
- Soiled bedding or strong urine smell in room
- Residents still in pajamas or nightgowns mid-afternoon
- Dentures not being cleaned
Bathing and grooming are time-intensive. When staffing is inadequate (RN hours below 0.5/resident/day), these "non-critical" tasks get skipped. Check our staffing guide for benchmarks.
4. Infection Control Failures
What this means: Facilities must have infection control programs to prevent spread of disease. Failures here lead to outbreaks of flu, COVID-19, UTIs, and antibiotic-resistant infections.
- Staff not washing hands between residents
- Gloves worn continuously instead of changed per resident
- Isolation protocols not followed (for contagious residents)
- Frequent UTIs, respiratory infections, or skin infections
- Wound care performed without proper sterile technique
- Common areas not being cleaned regularly
5. Medication Errors and Mismanagement
What this means: Wrong medications, wrong doses, or missed medications can cause serious harm—falls from over-sedation, pain from missed medications, medical emergencies from drug interactions.
- Excessive drowsiness or confusion (possible over-medication)
- Sudden personality changes
- Complaints of pain when on pain medication (may not be given)
- Medications not locked away properly
- Unlabeled or expired medications in room
- Staff can't explain what medications are being given or why
"Can I see the medication administration record (MAR)?" Check that medications are being signed off as given—not doses being skipped.
6. Falls and Accident Hazards
What this means: Facilities must identify fall risks and take steps to prevent them. Repeated falls, especially during the same shift or under similar circumstances, suggest neglect.
- Multiple unexplained bruises, especially on arms, legs, or face
- Broken bones (hip fractures are particularly serious)
- Falls always happening during same shift (suggests understaffing)
- Call lights not being answered promptly
- Bed rails not used when prescribed (or used when not prescribed)
- Wet floors, poor lighting, or obstacles in walking paths
- Residents without proper footwear
One fall can be an accident. Three falls in two months is a pattern. Ask for the fall log and incident reports.
7. Isolation and Emotional Neglect
What this means: Residents have the right to dignity, activities, and social interaction. When facilities are understaffed, emotional and social needs get ignored. This leads to depression, cognitive decline, and physical deterioration.
- Resident always alone in room during visits
- No participation in activities (when they previously enjoyed them)
- Depression, withdrawal, or resignation
- Television always on the same channel (no one asking preferences)
- Lack of personal items, decorations, or familiar objects in room
- No evidence of social interaction with other residents
Facilities with staff turnover above 60% have significantly more quality of life violations. High turnover means no one knows residents well enough to engage them meaningfully.
Behavioral Warning Signs in Residents
Sometimes the clearest signs come from how residents act around staff or during your visits.
🚩 Red Flag Behaviors
- •Fear or anxiety when certain staff members enter the room
- •Flinching when approached or touched
- •Reluctance to talk when staff are present
- •Sudden personality changes or withdrawal
- •Begging to go home or not be left alone
Staff Behavior to Watch
- •Defensive or hostile when you ask questions
- •Preventing you from talking to your loved one alone
- •Visible stress, rushing, or seeming overwhelmed
- •Inconsistent answers about resident's care
- •Rough handling or dismissive attitude toward residents
Trust Your Instincts
If something feels wrong, it probably is. Facilities with staff turnover rates above 60% have 38% lower star ratings and significantly more violations. Stressed, overworked staff can't provide good care—no matter how much they want to.
What to Do If You Suspect Neglect
Seeing warning signs doesn't mean you're powerless. Here's exactly what to do.
Step 1: Document Everything
- Take photos (if facility policy allows) - bruises, hygiene issues, room conditions
- Write detailed notes with dates and times of incidents
- Record conversations (within legal limits in your state)
- Save emails and written communications
- Note who was on duty when issues occurred
Step 2: Talk to Facility Administration
Start with the Director of Nursing or Administrator. Sometimes issues stem from staffing problems or communication breakdowns that management can fix.
Give them a chance to correct the issue—but set a timeline. "I need to see X improved within one week" is reasonable.
Step 3: File a Formal Complaint
If the facility doesn't respond or the neglect continues:
- State Ombudsman: Advocates for nursing home residents. Find yours at theconsumervoice.org
- State Survey Agency: Conducts inspections and investigates complaints
- Adult Protective Services: For suspected abuse or severe neglect
Step 4: Consider Relocation
If you see immediate jeopardy violations (J-K-L level citations) or repeated serious neglect, move your loved one.
Research first. Use our facility search tool to find higher-rated facilities with better inspection records.
Your Rights
Facilities cannot retaliate against you for filing complaints. It's illegal. If they threaten discharge or mistreat your loved one after a complaint, that's additional grounds for enforcement action.
You have the right to see inspection reports, deficiency citations, and your loved one's care plan at any time.
How to Prevent Neglect Before It Happens
The best defense is choosing a facility with a strong track record and staying involved.
During Your Search
- Check deficiency history first. Use our database to filter out facilities with J-K-L violations.
- Look at staffing levels. RN hours below 0.5/resident/day = red flag. Above 0.75 = good sign.
- Check turnover rates. Above 60% staff turnover? Quality suffers.
- Read the full inspection report, not just the star rating. Look for patterns.
- Tour at different times including evenings and weekends when staffing is lowest.
After Placement
- Visit frequently and unpredictably. Drop by at different times, including meals and shift changes.
- Build relationships with frontline staff. CNAs and nurses know what's really happening.
- Attend care plan meetings. Speak up if needs aren't being met.
- Know the ombudsman. Post their contact info in your loved one's room.
- Join the family council if the facility has one. Collective voices get heard.
The Power of Presence
Residents with frequent visitors receive better care. It's not fair, but it's documented. Your presence signals to staff that someone is watching and cares.
Quality Metrics That Predict Neglect Risk
Based on our analysis of all 14,751 facilities, here's how quality metrics correlate with neglect risk.
| Factor | 5-Star Facilities | 1-Star Facilities | Impact |
|---|---|---|---|
| RN Hours/Resident/Day | 0.77 | 0.51 | +51% more RN time |
| Staff Turnover Rate | 38.6% | 53.4% | 38% lower turnover |
| Abuse Violations | 0% | 26.4% | Zero tolerance |
| Immediate Jeopardy Citations | Rare | Common | Strong predictor |
Use Our Data
Our facility search lets you filter by:
- Staffing levels (RN hours, total nurse hours, turnover)
- Deficiency history (type, severity, frequency)
- Star ratings (overall and component ratings)
- Abuse violations (zero tolerance filter)
Find facilities with clean records before neglect becomes an issue.
Research Facilities Before Neglect Happens
Search our database of 14,751 facilities. Filter by deficiency types, view inspection histories, and find facilities with clean records in your area.
Find Quality Care Facilities
Use these warning signs to identify high-quality nursing homes:
Methodology
This guide is based on analysis of 411,456 deficiency citations from the CMS Health Deficiencies dataset, covering all 14,751 Medicare-certified nursing homes in the United States.
Data sources:
- CMS Health Deficiencies (Dataset r5ix-sfxw)
- CMS Provider Information (Overall ratings, staffing)
- Citations from the last 3 years of inspections
Statistics represent actual government inspection findings, not estimates or surveys. All percentages calculated from the full citation database.
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