Over the past five years, more than 2,000 elderly residents have walked away from assisted-living facilities in America or been left unattended outside, according to a Post investigation; nearly 100 have died. Some states have done little to recognize or measure the problem, much less prevent it, experts say.
“The top recommendation for patient safety would be to have better regulations,” said Helena Temkin-Greener, a public health scientist at the University of Rochester who has studied patient safety in assisted-living facilities (though not specifically the problem of walkaways, which are known in the industry as “elopements”).
Research suggests that mandatory staffing ratios could improve resident outcomes. But staff-to-resident ratios are rare across America, The Post found, with only 13 states requiring them. Most states simply mandate that assisted-living facilities have “sufficient” staff working at any given time, without saying what that means.
When states switch from requiring “sufficient” staff to a specific ratio — such as Mississippi’s requirement of 1 staffer per 15 residents by day and 25 residents by night — the monthly risk of suffering an injury or illness requiring hospitalization dropped 4 percent for residents, according to a 2021 study in the journal Health Affairs. The risk dropped even more — by 6 percent — among residents diagnosed with dementia.
Other studies have found that staff training plays an even greater role in keeping residents safe, especially residents with dementia. But training requirements vary widely, The Post found, from five hours in Maryland to 90 hours in Kansas. Almost half of states require training but do not mandate how many hours. Tennessee requires no training at all, except for staff working in memory care units.
Many states require workers in specialized memory care units to get training about dementia, but fewer than half require such training for all workers, The Post found. Even fewer — just nine states — require all workers to get at least six hours of dementia training, the minimum recommended by the Alzheimer’s Association.
Experts say such training is important because not all residents with dementia live in specialized memory care units. Training all staff to recognize the signs of dementia and to interact appropriately with people suffering from memory loss could help prevent walkaways.
Transparency also is inconsistent from state to state. Most states require inspections yearly or every two years, while Wyoming requires them every three years and Nebraska every five years. In 29 states, residents can look up recent inspection reports and complaints about assisted-living facilities online.
But some websites are easier to navigate than others. And in some states, inspection reports and complaints are made available only after a public records request. New Hampshire does not release complaint investigations at all.
When inspections uncover problems, the level of enforcement varies, as do potential fines. In three states — Connecticut, South Dakota and Wyoming — inspectors cannot issue fines
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Below is a summary of key assisted-living rules in each state, along with the approximate number of assisted-living facilities and their licensed bed capacity. In some states, regulations may call facilities something other than assisted living; some facilities may house younger adults as well as seniors. In most states, officials confirmed that these rules were accurate at the time of publication; six states did not respond.
Alabama
310 facilities with about 11,150 beds.
Requires mandatory staff ratios and six hours of training on dementia for workers in assisted-living facilities licensed to house people with dementia. The public can look up annual inspection reports and complaints.
Alaska
710 facilities with about 4,840 beds.
Requires no specified number of hours of training before assisted-living staff can start work; a state spokesperson noted that workers must be supervised for their first three days on the job and are required to get 12 hours of continuing education each year. No required staff-to-resident ratio, and no requirement that all direct-care workers participate in training on dementia. The public cannot look up complaints or inspection reports online.
Arizona
1,900 facilities with about 42,120 beds.
Requires 62 hours of training for assisted-living workers, including four hours on dementia. No mandatory staff-to-resident ratio. The public can look up complaints and inspections.
Arkansas
110 facilities with about 7,010 beds.
Mandates staff-to-resident ratios, which vary based on the time of day. Workers must participate in 30 hours of training. A law passed this year requires four hours of dementia training. The public cannot look up complaints or inspections online.
California
7,910 facilities with about 178,320 beds.
Requires workers to participate in 40 hours of initial training and 20 hours of training on an annual basis, including 12 hours of initial training on dementia. No mandated staffing ratios. The public can look up complaints and the results of inspections.
Colorado
710 facilities with about 25,400 beds.
Requires all direct-care workers to participate in four hours of initial training on dementia and an unspecified number of hours on other topics. No mandated staffing ratios. The public can look up inspections and complaints.
Connecticut
120 facilities with about 8,000 beds.
Requires workers to participate in 10 hours of initial training and another six hours of training each year. No specific requirement that a certain number of those hours focus on dementia. No mandated staffing ratios. The public can look up complaints and inspection reports.
Delaware
30 facilities with about 2,630 beds.
Requires workers who provide direct care to participate in 12 hours of ongoing education each year. No specific number of hours for dementia training. No mandated staffing ratios. The public can look up complaints and annual inspection reports.
District of Columbia
20 facilities with about 1,200 beds.
Requires 40 hours of training for new workers in assisted-living facilities who do not already have medical training. A 2020 law requires eight hours of training focused on dementia, but it has not yet gone into effect. The District used to post inspection reports online but has not posted new reports for several years.
Florida
2,940 facilities with about 112,490 beds.
Requires new workers to participate in 12 hours of training, including four hours on dementia. Requires facilities to have enough staff to work a certain number of hours per week, based on the number of residents. The public can look up complaints and the reports from annual inspections.
Georgia
1,680 facilities with about 43,530 beds.
Requires mandatory staff-to-resident ratios and 24 hours of training for new care workers in their first year on the job. Workers in memory care units must spend eight hours of that training learning about dementia. The public can read complaints and inspection reports online.
Hawaii
20 facilities with about 2,600 beds.
No specific requirements for the number of hours of initial training or training on dementia. Requires six hours of ongoing education each year for direct-care workers. No mandated staffing ratios. The public can look up inspection reports.
Idaho
260 facilities with about 10,480 beds.
Requires direct-care workers to participate in 16 hours of training before they start work and eight hours of ongoing education each year. No specific number of hours of training on dementia. No mandated staffing ratios. The public can look up complaints and the results of annual inspections.
Illinois
520 facilities with about 28,350 beds.
Requires eight hours of ongoing education each year for direct-care workers. Training on dementia is only required for workers in memory care units. No mandated staff-to-resident ratios. The public cannot look up complaints or inspection reports online.
Indiana
370 facilities with about 32,630 beds.
Requires a minimum ratio of nurses on duty to residents who require care from nurses. Requires all new direct-care workers to participate in six hours of training on dementia and an unspecified number of hours on other topics. The public can look up complaints and the results of inspections.
Iowa
500 facilities with about 28,040 beds.
Requires two hours of dementia training and an unspecified number of hours of training on other topics for new care workers. Workers in memory care units must have an additional six hours of dementia training. No mandated staffing ratios. The public can look up complaints and the results of inspections.
Kansas
480 facilities with about 14,850 beds.
Requires 90 hours of training for workers who start in assisted-living facilities without prior medical training. No mandated staffing ratios. The public can look up complaints and inspection reports.
Kentucky
110 facilities with about 5,400 beds.
Does not specify how many hours of training workers must receive. Requires workers in memory care units to receive eight hours of training on dementia. No mandated staff-to-resident ratios. There are no inspection reports online.
Louisiana
160 facilities with about 9,110 beds.
Requires new care workers to participate in two hours of training on dementia, part of an unspecified number of hours of initial training, plus 12 hours of ongoing education each year. Requires direct-care workers in memory care units to receive six additional hours of training on dementia. No mandated staffing ratios. The public cannot look up complaints and inspection reports without submitting a public records request.
Maine
1,100 facilities with about 9,870 beds.
Sets mandatory staff-to-resident ratios based on the time of day. Requires 16 hours of training on dementia for workers in dementia units, not for all direct-care workers. Does not publish complaints or inspection reports online; a state spokesperson said that a website with that information is coming “in the future.”
Maryland
1,820 facilities with about 26,160 beds.
Requires new workers to participate in five hours of training on dementia and an unspecified number of hours on other topics. No mandated staffing ratios. The public can look up complaints and inspection reports.
Massachusetts
270 facilities with about 19,790 beds.
Requires 61 hours of training for new direct-care workers who do not already have medical training, including two hours of training on dementia. No mandated staffing ratios. Requires a public records request to release inspection reports or complaints.
Michigan
4,020 facilities with about 54,770 beds.
Requires some regulated assisted-living facilities to maintain specific staff ratios, but not all facilities must be regulated. Does not specify the number of hours of training for new workers. The public can look up complaints and inspection reports for regulated facilities.
Minnesota
2,220 facilities with about 62,840 beds.
Requires new direct-care workers to participate in eight hours of training on dementia and an unspecified number of hours of training on other topics. No mandated staffing ratios. Residents can look up complaints and the results of annual inspections.
Mississippi
200 facilities with about 8,430 beds.
Mandates staff-to-resident ratios. Does not specify the number of hours of training that workers must receive, initially or on an annual basis. Members of the public must submit a public records request to view inspection reports or complaints.
Missouri
630 facilities with about 28,090 beds.
Mandates staff-to-resident ratios. Requires new direct-care workers to participate in three hours of training on dementia and at least two hours of training on other topics. The public can look up complaints and inspection reports.
Montana
210 facilities with about 5,730 beds.
Requires two hours of training on dementia for new workers; does not specify how many hours of training workers must receive on other topics. No mandated staffing ratios. Limited information on inspections and complaints can be found online.
Nebraska
280 facilities with about 13,830 beds.
Does not specify how many hours of training workers must participate in before they start caring for assisted-living residents, nor require a specific number of hours of initial training on dementia. Requires 12 hours of ongoing education each year for direct-care workers. No mandated staffing ratios. Some information on inspections and complaints can be found online, but new reports have not been posted in recent years.
Nevada
400 facilities with about 9,410 beds.
Requires new direct-care workers to participate in eight hours of training on dementia. Requires a ratio of 1 worker to every 6 residents in memory care units during daytime hours. The public can look up limited information about facilities.
New Hampshire
140 facilities with about 6,750 beds.
Requires new direct-care workers to participate in six hours of training on dementia. No mandated staffing ratios. While some inspections are online, a state spokesperson said that complaints are “confidential” and not released to the public.
New Jersey
290 facilities with about 26,680 beds.
Requires new direct-care workers to participate in 16 hours of training. No mandated staffing ratios. The public can look up complaints and the results of annual inspections.
New Mexico
230 facilities with about 6,170 beds.
Requires minimum staff-to-resident ratios and at least 16 hours of training for new direct-care workers, including four hours of training on dementia. The public can look up complaints and annual inspection reports.
New York
560 facilities with about 51,890 beds.
Requires new direct-care workers to participate in 40 hours of training, plus 12 hours of ongoing training each year. No mandated staffing ratios. The public can look up citations of assisted-living facilities, though full inspection reports are not available online.
North Carolina
580 facilities with about 37,150 beds.
Mandates staff-to-resident ratios. Requires 80 hours of training for most direct-care workers. Requires workers in memory care units to train for six hours on dementia initially, and another 20 hours in the next six months. The public can look up complaints and inspection reports.
North Dakota
140 facilities with about 5,280 beds.
Requires workers in one of two categories of assisted-living homes to participate in eight hours of training on dementia. No mandatory staffing ratios. Requires a public records request to access information about complaints.
Ohio
800 facilities with about 68,000 beds.
Requires new direct-care workers to participate in four hours of training on dementia and an unspecified number of hours of training on other topics. No mandated staffing ratios. The public can look up complaints and annual inspection reports.
Oklahoma
190 facilities with about 12,050 beds.
Requires new direct-care workers to participate in 75 hours of initial training, including 10 hours on dementia, and an additional 24 hours of ongoing education each year. No mandated staffing ratios. The public can look up complaints and annual inspection reports.
Oregon
580 facilities with about 30,000 beds.
Does not require a specific number of hours of initial training; requires 12 hours of ongoing education each year for direct-care workers. No mandated staffing ratio but a recent law requires the state to approve each facility’s level of staffing. The public can look up complaints and inspection reports.
Pennsylvania
1,050 facilities with about 63,320 beds.
Requires 18 hours of training for new direct-care workers, including four hours on dementia. No mandated staffing ratios. The public can look up complaints and inspection reports.
Rhode Island
60 facilities with about 4,950 beds.
Requires 10 hours of training for new direct-care workers. No mandated staffing ratios. The public can look up complaints and inspection reports.
South Carolina
460 facilities with about 22,100 beds.
Mandates staff-to-resident ratios. Does not require a specific number of hours of training for workers, either initially or on an annual basis. Inspection reports and complaints are not online and require a public records request, which costs more than $100 per facility and takes about six weeks.
South Dakota
160 facilities with about 5,160 beds.
Does not set staffing ratios. Does not require a specific number of hours of training for workers, either initially or on an annual basis. Inspection reports and complaints are not online; they require a public records request.
Tennessee
380 facilities with about 23,990 beds.
Requires staff in memory care units to have some training on dementia but requires no other training for assisted-living workers. No required staffing ratio. Inspection reports are available only on a limited basis.
Texas
2,000 facilities with about 81,320 beds.
Requires 20 hours of training for new direct-care workers. Requires four hours of training on dementia for workers in memory care units. No required staffing ratios. Inspection reports and complaints are not available online.
Utah
220 facilities with about 12,250 beds.
Requires new direct-care workers to participate in 16 hours of training. No mandated staffing ratios. The public cannot look up complaints or inspections online; a state spokeswoman said the state would publish the reports “in the very near future.”
Vermont
120 facilities with about 3,340 beds.
Requires no staffing ratio. Requires no specific hours of initial training, but requires 12 hours of ongoing education each year for direct-care workers. The public can look up complaints and annual inspection reports.
Virginia
570 facilities with about 38,270 beds.
Requires direct-care workers to participate in at least 14 hours of initial training, including six hours on dementia. Mandates staffing ratios for memory care units. The public can look up complaints and annual inspection reports.
Washington
550 facilities with about 37,910 beds.
Requires direct-care workers to participate in 12 hours of training each year. No mandated staffing ratios. The public can look up complaints and annual inspection reports.
West Virginia
90 facilities with about 3,580 beds.
Requires new direct-care workers to participate in two hours of training on dementia, plus an unspecified number of hours on other topics. The public can look up complaints and annual inspection reports.
Wisconsin
4,030 facilities with about 60,160 beds.
Training requirements vary based on the regulatory category of the facility. All workers must be trained, but some must participate in 15 hours of initial training, while some need an unspecified number of hours of training. No mandated staffing ratios. The public can look up complaints and inspection reports online.
Wyoming
30 facilities with about 1,660 beds.
Does not specify the number of hours of training that new workers must participate in. Requires 12 hours of ongoing education each year, with workers in memory care units required to focus on dementia. No mandated staffing ratios. The public can look up complaints and the results of inspections.
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