# Assisted living vs nursing home: rules, records and liability

> Assisted living vs nursing home: who regulates each, which records exist, staffing and arbitration rules, and what the difference means in a lawsuit.

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Field guide, September 2026. 14 chapters.

## Assisted living vs nursing home: the difference in care, rules and records

For families comparing options, and for the attorneys, legal nurse consultants and experts who handle long-term care claims on either side. You walk away with a side-by-side of both settings, a decision path for which rules apply to a facility, a records map for each, and 3 templates.

By [Ahmed Jemaa](https://medrecords.ai/authors/ahmed-jemaa/), Co-Founder and CEO, Medrecords AI. Published 26 September 2026.

Assisted living vs nursing home comes down to care level and regulation. A nursing home provides 24-hour nursing care and, when it takes Medicare or Medicaid, must meet the federal requirements in 42 CFR Part 483, including MDS assessments and federal inspections. Assisted living provides housing, meals and help with daily activities, and each state licenses and regulates it, with no federal operating standard.

A family asking "assisted living vs nursing home" wants to know which one fits a parent. A lawyer on a long-term care claim needs a different answer: which rulebook governed the building, and which records that rulebook forced it to keep. Both answers start from the same fact. A nursing home that takes Medicare or Medicaid runs under 1 federal rulebook, and an assisted living community runs under whatever its state wrote.

This guide is built from 42 CFR Part 483 as current in September 2026, the HCBS settings rule at 42 CFR 441.301(c), 42 USC 1395i-3, the Federal Arbitration Act, the HIPAA rules at 45 CFR 160.103 and 164.524, the CMS rules of 2019 (arbitration) and 2025 (staffing repeal), CMS Appendix PP, the MDS 3.0 RAI Manual, GAO-19-599, GAO-26-107884, CDC FastStats, and Florida Statutes chapter 429 as 1 example of a state assisted living law. Assisted living rules differ by state. Every case example is a labeled hypothetical. Nothing here is legal or medical advice.

10 numbers

### The 2 settings in 10 numbers

14,700
nursing homes in the US in 2022, with about 1.2 million residents
CDC NCHS FastStats, nursing home care
32,200
residential care communities, including assisted living, in 2022, with 988,800 residents
CDC NCHS FastStats, residential care communities
44 states
whose Medicaid programs covered assisted living services as of March 2025
GAO-26-107884, 2026
14 days
after admission: deadline for a nursing home's comprehensive resident assessment (the MDS)
42 CFR 483.20(b)(2)(i)
48 hours
after admission: deadline for a nursing home's baseline care plan
42 CFR 483.21(a)(1)(i)
30 days
calendar days a nursing home resident has to rescind a binding arbitration agreement
42 CFR 483.70(m)(3)
5 years
from discharge: nursing home record retention when state law sets no period
42 CFR 483.70(h)(4)(ii)
15 months
longest gap allowed between standard surveys of a Medicare skilled nursing facility; statewide average no more than 12
42 USC 1395i-3(g)(2)(A)(iii)
2 hours
to report an abuse allegation, or one causing serious bodily injury, to the administrator and state survey agency
42 CFR 483.12(c)(1)
Sep 30, 2034
last day of the period in which federal law bars CMS from enforcing the 2024 nurse staffing minimums, since repealed
Pub. L. 119-21, section 71111, per 90 FR 55687
Chapter 1 Everyone

### Assisted living vs nursing home: the plain answer

A nursing home is a health care facility for people who need nursing care around the clock. When a nursing home takes Medicare or Medicaid, it must meet the federal requirements in 42 CFR Part 483. Section 483.35 requires enough licensed nurses and nurse aides "on a 24-hour basis to provide nursing care to all residents," a registered nurse on duty at least 8 consecutive hours a day, 7 days a week, and a full-time RN director of nursing.

Assisted living is housing with help: a room or apartment, meals, and help with bathing, dressing and medications. The state licenses it and sets the rules. There is no federal operating standard. GAO put it plainly in 2019, comparing federal abuse reporting and investigation rules: there are "no similar federal requirements for assisted living facilities," which "are licensed and regulated by states." Some states allow limited nursing services; the scope varies by state. Florida's consent form for medication help tells the resident that an assisted living facility "is not required to have a licensed nurse on staff."

Money follows the same split. GAO reported in 2026 that Medicare "generally does not cover assisted living services," though it pays for care delivered there, such as hospice. Medicaid programs in 44 states covered assisted living services as of March 2025, 29 of them through home and community-based services waivers.

Assisted living fits a person who needs help with daily tasks but is medically stable. A nursing home fits a person who needs a nurse's judgment every day. State law draws the line, and chapter 9 shows how lawsuits start there.

##### Nursing home (Medicare or Medicaid certified)

Who writes the rulesCMS, in 42 CFR Part 483, plus the state licenseCare level24-hour nursing careNurse on siteLicensed nurses 24 hours; RN at least 8 consecutive hours dailyStandard assessmentThe federal MDS 3.0, on a fixed calendarInspectionsState survey agency on CMS's behalf; results on Form CMS-2567ArbitrationAllowed, but never as a condition of admission; 30 days to rescind

##### Assisted living

Who writes the rulesThe state licensing statute and regulationsCare levelHelp with daily activities; nursing only as state law allowsNurse on siteDepends on the state; often not requiredStandard assessmentA state form or the facility's own; no MDSInspectionsState licensing agency, on the state's scheduleArbitrationNo federal nursing home rule; contract law and the Federal Arbitration Act

#### The full side-by-side

The nursing home column cites the federal rule. The assisted living column uses Florida where an example helps; check your own state before relying on any row.

| Topic | Nursing home (Part 483) | Assisted living (state law) |
| --- | --- | --- |
| Governing law | 42 CFR Part 483, the condition of Medicare and Medicaid participation (483.1) | State licensing law; licensed and regulated at the state level (GAO-26-107884) |
| Nursing staff | Licensed nurses and aides 24 hours; RN 8 consecutive hours daily; RN director of nursing (483.35) | Set by the state; Florida law tells residents a facility is not required to have a licensed nurse on staff (429.256) |
| Numeric staffing minimum | None federally; the 2024 minimums were vacated in 2025 and removed effective February 2, 2026 | Set by the state, if at all |
| Admission assessment | Comprehensive MDS assessment within 14 calendar days (483.20(b)(2)(i)) | State or facility form; Florida: medical exam 60 days before to 30 days after admission (429.26(5)) |
| Reassessment | Quarterly; comprehensive yearly and within 14 days of a significant change (483.20) | State schedule; Florida: monthly nurse assessment only where nursing services are provided (429.26(4)) |
| Care plan | Baseline in 48 hours; comprehensive 7 days after the assessment (483.21) | Service plan under state rules; person-centered plan for waiver residents (441.301(c)) |
| Physician involvement | Physician visit at least every 30 days for the first 90 days, then at least every 60 days (483.30(c)) | Resident's own doctor; no federal schedule |
| Medications | Nurses administer; monthly pharmacist review (483.45(c)) | Aides may assist with self-administration where the state allows (Florida 429.256) |
| Change in condition | Immediately inform resident, physician and representative (483.10(g)(14)) | State rules; Florida nurses document changes that may need relocation (429.26(4)) |
| Abuse reporting | 2 or 24 hours to the state survey agency; results in 5 working days (483.12(c)) | State law; Medicaid agency policies for waiver residents (GAO-19-599) |
| Restraints | Never for discipline or convenience; least restrictive, shortest time (483.12(a)(2)) | State limits; Florida defines physical and chemical restraint (429.02) |
| Discharge | 6 permitted grounds, 30 days' notice in most cases, appeal rights (483.15(c)) | Contract and state law; tenant-like eviction protections for waiver residents (441.301(c)(4)(vi)(A)) |
| Arbitration | Never a condition of admission; 30 days to rescind (483.70(m)) | Contract law, 9 USC 2, any state statute |
| Inspections | Within 15 months of the last survey (42 USC 1395i-3(g)(2)(A)(iii)) | State licensing schedule |
| Public inspection results | Form CMS-2567, public within 14 days (1395i-3(g)(5)(A)); posted in the building (483.10(g)(11)) | Varies by state agency |
| Medical record retention | State period, or 5 years from discharge (483.70(h)(4)) | State rules |
| Resident access to records | Inspect in 24 hours; copies in 2 working days (483.10(g)(2)) | HIPAA's 30 days if a covered entity (164.524); else state law |

If you remember one thing
Before you read a single chart, find out which column the facility belongs in. Every deadline, every missing-record argument and every standard in the case depends on that answer.

Chapter 2 Everyone

### Which rules apply to this facility

Do not go by the sign out front. "Senior living," "memory care" and "residence" are marketing words; the license and the certification decide. GAO noted in 2026 that assisted living facilities "are not a uniformly defined provider type," and states use many names for them. A single campus can hold a certified nursing wing and a state-licensed assisted living building, and a resident may move between them. Work the questions in order.

**Which rules apply: a decision path** — 5 questions — 42 CFR 483.1, 441.301(c); 45 CFR 160.103; GAO-19-599
1
**Is the building, or the wing the resident lived in, certified as a Medicare skilled nursing facility or a Medicaid nursing facility?**
YesPart 483 applies: MDS, care plans, federal surveys, Form CMS-2567, the arbitration rule. State licensure rules apply on top.
NoPart 483 does not apply. Go to question 2.
2
**What license does the state issue for the building?**
Assisted living or similarThe state statute and rules set the standard. Pull the versions in force during the stay.
UnlicensedAsk why. Either answer shapes the case.
3
**Did Medicaid pay for the resident's assisted living services through a home and community-based services waiver?**
YesThe HCBS settings rule at 441.301(c)(4) and a person-centered service plan also apply, and the state Medicaid agency's abuse reporting policies reach the facility.
NoState licensing law and the residency contract govern.
4
**Did Medicare pay for services inside the assisted living community, such as hospice or home health?**
YesThose agencies keep their own records. Request them separately.
NoThe facility file and the outside physicians' charts are the main sources.
5
**Does the facility bill health plans electronically?**
YesIt is likely a HIPAA covered entity under 45 CFR 160.103, and the 30-day access rule in 164.524 applies to a resident's request.
NoHIPAA may not reach it. State law and the contract control access; plan on a subpoena or authorization under state rules.
The license and the payer, not the name on the sign, decide which rulebook applies.

#### Who pays tells you which records exist

Payer records are an often overlooked source in assisted living cases. A Medicaid waiver means a person-centered service plan reviewed at least every 12 months, when needs change significantly, or on request (441.301(c)(3)). Medicare hospice means a hospice chart with its own nursing visits. Those outside files can describe the resident more candidly than the facility's notes, because the outside nurse has no stake in whether she can stay.

**Federal spending on services in assisted living, 2024** — at least $12 billion total — GAO-26-107884, 2026
Medicare generally does not pay for assisted living services, yet GAO identified more traditional Medicare spending there than federal Medicaid spending, most of it hospice ($6.1B) and home health ($1.4B). GAO calls both figures likely undercounts. Each of those dollars left a record outside the facility.

Nursing homes14,700 in 2022
72.4% for-profit — 27.6% other
Residential care32,200 in 2022
81.5% for-profit — 18.5% other
**For-profit — **Nonprofit, government and other
Both settings are mostly for-profit, per CDC's 2022 figures. For discovery, ask early where the policy manual, incident database and staffing records are kept; in a chain, that may be a regional office.

If you remember one thing
Get the license and certification status for the exact dates of the stay, and ask who paid for every service. The answers tell you which regulator, which rulebook and which outside records to chase.

Chapter 3 Building

### The records map for each setting

The nursing home chart is built to a federal specification. Section 483.70(h) requires records that are "complete," "accurately documented," "readily accessible" and "systematically organized," and lists what they must contain: identifying information, the resident's assessments, the comprehensive care plan and services provided, preadmission screening (PASARR) results, progress notes from physicians, nurses and other licensed professionals, and lab and radiology reports. The assisted living file follows the state's rules, which may ask for far less.

##### Nursing home file

Expect every item; a gap is a finding

- Admission agreement and any separate arbitration agreement
- PASARR screening results
- MDS 3.0 assessments: admission, quarterly, annual, significant change
- Baseline and comprehensive care plans with revisions
- Physician orders and visit notes
- Nursing progress notes, flowsheets, MAR and treatment records
- Monthly pharmacist drug regimen reviews
- Lab and radiology reports
- Notices of change in condition to physician and family
- Incident and accident reports, abuse allegation reports and 5-day investigation reports
- Transfer and discharge notices
- Daily posted nurse staffing sheets, payroll-based staffing data, the facility assessment
- Form CMS-2567 survey reports and plans of correction

##### Assisted living file

Expect what the state requires; confirm each item

- Residency agreement or contract, often with an arbitration clause inside it
- Pre-admission medical examination form
- State assessment form or the facility's own assessment
- Service plan and its updates
- Medication assistance record kept by aides, and the resident's written consent to assistance
- Nurse assessments, only if the facility provides nursing services
- Outside physician orders, often faxed
- Incident reports and any internal investigation
- Move-out or discharge notice
- For Medicaid waiver residents: the person-centered service plan and case manager notes
- Hospice or home health records kept by outside agencies
- State licensing inspection reports

#### What does not exist in assisted living, and why that cuts both ways

There is no MDS in assisted living, no federal care plan deadline, no federal survey and no federal staffing data. Send a nursing home request list to an assisted living community and you will get a pile of "no such record" answers. Usually that is not spoliation. The record was never required.

That cuts both ways. For the plaintiff, the thinness of the file can be the story: a resident whose needs grew for 8 months with no reassessment on paper. For the defense, the thinness is the law: the state did not require the document, so its absence proves nothing about care. Our view: before either side argues about a missing assisted living record, it should put the state rule on the table. The argument is only as strong as the requirement behind it.

Outside records are where assisted living cases are won or lost. In a nursing home, the physician's note usually sits in the facility chart. In assisted living, the resident's doctor practices across town, and the note of the last office visit exists only in that office's system. The pharmacy has a dispensing history the facility never saw. Build the provider list from the facility file, then request every outside chart it names.

If you remember one thing
Do not treat a missing assisted living record as a gap until you have found the state rule that required it. Then chase the outside providers, because that is where the clinical picture lives.

Chapter 4 Building

### Inside the nursing home record: MDS, care plans and their clocks

The federal nursing home chart runs on clocks. Each produces a document on a predictable date, so each produces a provable gap when the document is late or missing.

**The admission clocks** — federal minimums — 42 CFR 483.20 and 483.21
Day 0 — **Admission** — Physician orders, PASARR results and the admission nursing assessment start the chart.
48 hours — **Baseline care plan** — Initial goals, physician and dietary orders, therapy and social services, PASARR recommendations (483.21(a)).
Day 14 — **Comprehensive MDS** — Completed within 14 calendar days after admission, using the resident assessment instrument (483.20(b)(2)(i)).
+7 days — **Comprehensive care plan** — Within 7 days after the comprehensive assessment, by the interdisciplinary team (483.21(b)(2)(i)).
After admission the clocks keep running: a quarterly review at least every 3 months, a new comprehensive assessment within 14 days of a significant change, and at least 1 comprehensive assessment every 12 months.

#### The MDS, section by section

The Minimum Data Set is the federal assessment form, organized in lettered sections (RAI Manual version 1.20.1, October 2025; version 1.20.11 takes effect October 1, 2026). Section 483.20(b)(1) requires direct observation of the resident and communication with licensed and nonlicensed direct care staff on all shifts. The facility encodes each assessment within 7 days, transmits it to CMS within 14 days, and keeps the previous 15 months in the active record.

| MDS section | Covers | What a reviewer checks it against |
| --- | --- | --- |
| A | Identification, entry and discharge | Admission and transfer dates in the census and hospital records |
| B, C, D, E | Hearing, speech and vision; cognitive patterns; mood; behavior | Nursing notes and psychiatric consults for the same look-back window |
| F | Preferences for customary routine and activities | Activity and social service notes |
| GG | Functional abilities and goals | Therapy notes, aide flowsheets, transfer and toileting documentation |
| H | Bladder and bowel | Toileting programs and continence records |
| I | Active diagnoses | Physician problem lists and hospital discharge summaries |
| J | Health conditions, including falls and pain | Incident reports, pain flowsheets, PRN analgesic use |
| K | Swallowing and nutritional status | Weights, dietitian notes, meal intake records |
| L | Oral and dental status | Dental consults and oral care records |
| M | Skin conditions | Wound assessments, photographs, treatment records |
| N | Medications | MAR, especially antipsychotics, anticoagulants and opioids |
| O | Special treatments, procedures and programs | Orders for oxygen, dialysis, therapy minutes |
| P | Restraints and alarms | Restraint orders, alarm use in nursing notes, fall care plans |
| Q | Participation in assessment and goal setting | Care conference notes, discharge planning |
| V | Care area assessment summary | Whether triggered care areas reached the care plan |
| Z | Assessment administration and signatures | Who completed each section and on what date |

The best review move is the simplest: lay the MDS next to the nursing notes for the same look-back window. If Section GG codes little help with transfers while aide flowsheets that week show 2-person assists, 1 record is wrong. Plaintiffs argue the facility did not know its own resident. The defense checks whether the windows differ or the resident improved. Either way, 483.20(g) requires the assessment to "accurately reflect the resident's status" (tag F641).

#### The other clocks: physicians, pharmacists, notification

- **Physician visits.** At least every 30 days for the first 90 days, then at least every 60 days (483.30(c)(1)).
- **Pharmacist review.** Each drug regimen at least monthly (483.45(c)(1)). The recommendation and the physician's response should both be on paper.
- **Change in condition.** After an injury accident, a significant change, a need to alter treatment significantly, or a transfer decision, the facility must immediately inform the resident, consult the physician and notify the representative (483.10(g)(14), tag F580). See our guide to [change in condition records](https://medrecords.ai/guides/nursing-home-change-in-condition/).
- **Abuse allegations.** Within 2 or 24 hours to the administrator and state survey agency, results within 5 working days (483.12(c), tag F609).

For the full nursing home record set, including how to read a Form CMS-2567, see the pillar guide on [nursing home records, the MDS and CMS-2567](https://medrecords.ai/guides/nursing-home-records-mds-cms-2567/).

If you remember one thing
Every federal clock produces a dated document. Build a calendar of what should exist from admission forward, then mark what the production actually contains.

Chapter 5 Building

### Inside the assisted living record: service plans, aides and medication help

There is no single assisted living chart. This chapter uses Florida's chapter 429 as a model of the questions to ask about your own state.

#### Admission: the medical exam and the fit decision

Florida requires a medical examination within 60 days before or 30 days after admission, recorded on a form that becomes a permanent part of the facility's record (429.26(5)). The owner or administrator decides whether a resident is appropriate for admission and for continued residency (429.26(1)), so there should be a person who made the fit decision and a document showing what they relied on.

Specialty licenses, such as limited nursing services and extended congregate care, allow more care inside the building (429.02). Check which ones the facility held during the stay.

#### Reassessment and the service plan

Where a Florida facility's nurses provide services ordered by a physician, they must assess the resident on a routine basis or at least monthly and document substantial changes that may require relocation to a nursing home or hospital (429.26(4)). Where it provides no nursing services, the file may hold no nurse assessment at all.

For Medicaid waiver residents, the HCBS settings rule requires a person-centered service plan, reviewed at least every 12 months, when the person's needs change significantly, or at the person's request (441.301(c)(3)). If a provider-controlled setting restricts a resident's freedoms, for example a locked door or limited access to food, the plan must document the specific assessed need, less intrusive methods tried first, ongoing data collection, time limits for review, informed consent and an assurance of no harm (441.301(c)(4)(vi)(F)). A locked memory care unit without that paper trail may have a waiver problem.

#### Medication help from unlicensed aides

In a nursing home, licensed nurses administer medications and chart them on a MAR. In Florida assisted living, an unlicensed person with required training may assist a medically stable resident with routine, regularly scheduled medications intended to be self-administered, but only after the resident's documented request and written informed consent (429.256(2)). The informed consent must tell the resident that the facility "is not required to have a licensed nurse on staff" and whether an unlicensed aide's help will be overseen by a licensed nurse (429.256(1)(a)). The facility must keep a record of when a resident receives assistance (429.256(3)(f)).

Assistance does not include injections, tube medications, "as needed" medications unless the order removes the aide's judgment, or any medication whose timing, amount, route or reason requires judgment (429.256(4)). Prefilled insulin pens count as labeled containers the aide may bring to the resident (429.256(3)(a)).

**Reading an assisted living medication assistance record** — hypothetical — Illustration; rules from Fla. Stat. 429.256
Medication assistance record Resident M.R., March
Consent
Request and consent — Signed by daughter, date blank1
Nurse oversight — Will Will not2
Scheduled
Metformin 500 mg, 08:00 and 17:00 — Initials each day; 03/14 to 03/16 blank3
Insulin pen, 10 units, 08:00 — Initials; dose "adjusted per sugar" 03/124
As needed
Lorazepam 0.5 mg PRN anxiety — Given 6 times in 4 days, no parameters5
ALF 000214
1. 1
**Consent** Florida requires a documented request and written informed consent before an aide assists. An undated form raises the question of whether assistance started first.
2. 2
**Oversight box left empty** The consent must say whether a licensed nurse oversees the aide. Neither box checked means the resident was never told.
3. 3
**Blank days** Refused, omitted, resident away, or just not charted? Match the dates to hospital, pharmacy and family records before calling it a missed dose.
4. 4
**Dose changed by the aide** Adjusting a dose calls for judgment, which the statute excludes from unlicensed assistance. The plaintiff reads scope violation; the defense will look for a sliding-scale order with fixed parameters.
5. 5
**PRN without parameters** Excluded from aide assistance unless the order removes independent judgment. Rising PRN use is also a change-in-condition signal.

Each pin maps to a line of the state statute. That is how you turn an aide's checklist into evidence, for either side.

#### Is an assisted living community covered by HIPAA?

Maybe. A health care provider is a covered entity when it transmits health information electronically in connection with a covered transaction, such as billing a health plan (45 CFR 160.103). A private-pay community that bills no insurer may not be. When HIPAA applies, the facility must act on an access request within 30 days (164.524(b)(2)); when it does not, state law and the contract control. See [how to get medical records for a lawsuit](https://medrecords.ai/guides/how-to-get-medical-records-for-a-lawsuit/) for the mechanics.

If you remember one thing
In assisted living, the medication record is kept by aides under a state statute that lists what they may and may not do. Read the record against that list line by line.

Chapter 6 Everyone

### Staffing rules, and what happened to the 2024 federal minimum

The federal staffing law changed twice in 2 years. A complaint or expert report that cites the 2024 minimums as binding law is wrong.

**The 2024 nursing home staffing rule, start to repeal** — 6 events — CMS-3442-IFC, FR doc 2025-21792, December 3, 2025
1. May 10, 2024
**CMS final rule sets numeric minimums**
An RN on site 24 hours a day, 7 days a week, and at least 3.48 total nurse staffing hours per resident day, including 0.55 RN and 2.45 nurse aide hours (89 FR 40876).

As summarized in the 2025 repeal rule
2. Apr 7, 2025
**Texas federal court vacates the minimums**
*American Health Care Association v. Kennedy*, 777 F. Supp. 3d 691 (N.D. Tex. Apr. 7, 2025), vacates the hours per resident day and 24/7 RN provisions at summary judgment on major questions grounds. Appealed to the Fifth Circuit on June 2, 2025.

Repeal rule, section I; the opinion
3. Jun 18, 2025
**Iowa federal court vacates the same provisions**
*Kansas v. Kennedy* (N.D. Iowa) reaches the same result at summary judgment.

Repeal rule, section I
4. Jul 4, 2025
**Congress imposes a moratorium**
Section 71111 of Public Law 119-21 bars CMS from implementing, administering or enforcing the minimums until after September 30, 2034.

Repeal rule, section II.A
5. Dec 3, 2025
**CMS repeals the minimums**
An interim final rule with comment period removes the numeric standards instead of leaving them on the books unenforced.

FR doc 2025-21792
6. Feb 2, 2026
**Repeal takes effect**
Current 42 CFR 483.35 carries no hours per resident day minimum and no 24/7 RN requirement.

eCFR, 483.35, amended 90 FR 55697

As of September 2026, the federal standard is "sufficient" staff plus an RN 8 hours a day. The numbers were never enforced.

#### What the federal nursing home staffing rule says now

Section 483.35 today requires sufficient numbers of licensed nurses and other nursing personnel, including nurse aides, "on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans," based on the facility assessment at 483.71. A licensed charge nurse covers each tour of duty. An RN works at least 8 consecutive hours a day, 7 days a week, and a full-time RN directs nursing. Posted daily nurse staffing data must be kept at least 18 months, or longer under state law (483.35(g)(4)), and payroll-based staffing data goes to CMS (483.70(p), tag F851). Sufficiency is surveyed under F725.

MythFederal law requires 3.48 nursing hours per resident per day.
RuleThat 2024 minimum was vacated by 2 courts, frozen by statute until after September 30, 2034, and repealed effective February 2, 2026.
MythNursing homes must have an RN on site around the clock.
RuleThe federal floor is an RN 8 consecutive hours a day, 7 days a week, plus licensed nurses 24 hours. Some states require more.
MythWith no numeric minimum, a staffing claim has nothing to measure against.
RuleStaff must be sufficient to carry out each resident's care plan, measured against the facility's own assessment. That is a fact question, and the facility's documents define it.
MythAssisted living must keep a nurse on duty.
RuleOnly if the state says so. Florida's consent form tells residents the facility is not required to have a licensed nurse on staff.

#### How each side uses staffing records

For the plaintiff, the strongest staffing case is specific: the care plan called for a 2-person transfer, the posted sheet shows too few aides on that shift, and the injury falls on that shift. The facility assessment, written by the facility, defines what "sufficient" meant there. For the defense, the same records can show staffing at the assessment's level, or an injury on a well-staffed shift. Compare the payroll data with the posted sheets; different people prepare them.

Assisted living has no federal staffing data. Ask for schedules, time clock records, agency invoices and any state-required ratios. If the service plan promised supervision, the schedule shows whether anyone was there to give it.

If you remember one thing
Do not cite the 2024 hours-per-resident-day minimums as current law. Argue staffing from the facility's own assessment, care plans and shift records.

Chapter 7 Deciding

### Arbitration agreements in each setting

Arbitration can decide where a case is heard before anyone reads a chart, and the rules differ sharply between the 2 settings.

#### Nursing homes: allowed, with conditions

The federal rule went back and forth. A 2016 rule banned pre-dispute binding arbitration agreements in nursing homes; a federal court in Mississippi preliminarily enjoined the ban on November 7, 2016. A 2019 rule, effective September 16, 2019, repealed the ban and substituted the conditions now at 42 CFR 483.70(m). If a facility asks a resident or representative to sign a binding arbitration agreement, then:

- **Not a condition of admission or continued care** *483.70(m)(1); the facility must also tell the resident of the right not to sign*
- **Explained in a form, manner and language the resident understands** *483.70(m)(2)(i)*
- **Resident acknowledges understanding the agreement** *483.70(m)(2)(ii)*
- **A neutral arbitrator agreed on by both parties** *483.70(m)(2)(iii)*
- **A venue convenient to both parties** *483.70(m)(2)(iv)*
- **Explicit right to rescind within 30 calendar days of signing** *483.70(m)(3)*
- **States plainly that signing is not required for admission or care** *483.70(m)(4)*
- **No language discouraging contact with federal, state or local officials, surveyors or the ombudsman** *483.70(m)(5)*
- **Signed agreement and final decision kept 5 years after resolution** *483.70(m)(6); available to CMS on request*

**0** of 9 checked

Surveyors cite these requirements under tags F847 (entering into binding arbitration agreements) and F848 (arbitrator and venue selection and retention of agreements). Whether a violation makes the agreement unenforceable in court is a separate question for your jurisdiction's case law.

#### Assisted living: contract law and the Federal Arbitration Act

No federal regulation governs arbitration in assisted living. The clause usually sits inside the residency agreement, and the Federal Arbitration Act treats it like any other contract term:

"A written provision in any maritime transaction or a contract evidencing a transaction involving commerce to settle by arbitration a controversy thereafter arising out of such contract or transaction ... shall be valid, irrevocable, and enforceable, save upon such grounds as exist at law or in equity for the revocation of any contract ..."

So the assisted living fight is about ordinary contract defenses, any state statute, and who signed. Both sides answer the same questions from the admission packet:

1. **Who signed, and with what authority?** Read the power of attorney or surrogate document to see whether it reaches legal claims or only medical decisions.
2. **When was it signed?** Compare the signature date with the move-in date and the medical exam form.
3. **Was it separate or buried?** A standalone agreement is harder to attack than a paragraph deep in a lease.
4. **Could the resident understand it?** Match the signing date to cognitive findings in the exam and physician notes.
5. **Is there an opt-out window?** Nothing federal requires one in assisted living. Check the contract, and whether anyone used it.

A resident who moved from assisted living into a certified wing on the same campus may have 2 agreements, only 1 of which must meet 483.70(m). Do not assume the second covers claims from the first stay.

If you remember one thing
Request the full admission packet with every signature page in the first letter. The arbitration fight, and the capacity evidence for it, is often decided by documents signed on day 1.

Chapter 8 Everyone

### Inspection reports and where each is published

Inspection reports are the record a family can read before choosing and a lawyer can pull before filing, without a subpoena.

15 months — maximum interval between standard surveys of a Medicare skilled nursing facility, 42 USC 1395i-3(g)(2)(A)(iii)
12 months — maximum statewide average interval between those surveys, same section
14 days — calendar days after a statement of deficiencies reaches the facility before it must be public, 1395i-3(g)(5)(A)
3 years — of survey, certification and complaint investigation reports a nursing home must show on request, 42 CFR 483.10(g)(11)

#### Nursing homes: Form CMS-2567

State survey agencies inspect certified nursing homes on CMS's behalf. Each standard survey must come no later than 15 months after the previous one, with a statewide average of no more than 12 months, and a state may run a special survey within 2 months of a change of ownership, administration, management or director of nursing (1395i-3(g)(2)(A)). Complaint investigations happen between standard surveys. Findings go on Form CMS-2567, the Statement of Deficiencies, where each citation carries an F-tag tied to a Part 483 requirement. The facility answers with a plan of correction.

The statute requires the state and CMS to make statements of deficiencies public within 14 calendar days after they are made available to the facility, along with approved plans of correction. The facility must post the most recent survey results where residents and visitors can reach them, and show the reports from the 3 preceding years on request (483.10(g)(10) and (11)). Appendix PP says "results of the most recent survey" means the Form CMS-2567, and the facility may not alter them unless the state agency authorizes it. Read the public copy, then request the agency's own file, including complaint intake and surveyor notes, through the state's public records process.

#### Assisted living: the state licensing agency

Assisted living inspections come from the state licensing agency, on the state's schedule, under state standards, with no federal form or publication rule. Some agencies post reports online; others release them only on request. If nothing is posted, send a public records request for inspection reports, complaint investigations and enforcement actions covering the stay and at least 2 years before it.

Plaintiffs look for a deficiency that matches the injury, near its date, on the same unit or practice. The defense looks for what the report does not say: no citation for the practice at issue, or a deficiency corrected before the injury. Admissibility of survey findings varies by jurisdiction; either way, they show where to look in the chart.

If you remember one thing
Pull inspection reports for at least 2 years before the injury before you draft the complaint or the answer. They show what the regulator already found, and what it did not.

Chapter 9 Deciding

### The resident who should have been moved to a higher level of care

The core assisted living liability case is a resident whose needs outgrew the building. She fit at move-in, then declined. The claim is that the facility kept her anyway. The defense answer is that it met the standard its license set and respected the family's choice to stay.

#### The legal hooks, using Florida as the example

- **Continued appropriateness.** The owner or administrator is responsible for "determining the continued appropriateness of residence," based on the resident's strengths, needs and preferences, a medical exam, and the facility's services (429.26(1)).
- **The outer limit.** No admitting or keeping a resident who is bedridden or needs 24-hour nursing supervision, except on hospice. "Bedridden" means confined to bed because the resident cannot move or reposition, or transfer to a chair, without total physical assistance, or cannot sit safely without personal assistance or a physical restraint; a stay of up to 7 consecutive days bedridden is allowed, or 14 with an extended congregate care license (429.26(1)(d)).
- **The nurse's paper trail.** Nurses providing ordered services assess at least monthly, document changes that may require relocation, and send the records to any case manager (429.26(4)).
- **The resident's choice.** A resident may not be moved from one facility to another without consultation with and agreement from the resident or, if applicable, the representative or family (429.26(2)). This is the defense's best statutory point.

Compare the nursing home rule. A certified facility that transfers a resident because it cannot meet her needs must have her physician document the specific unmet needs, what the facility tried, and what the receiving facility offers, and must copy the written notice to the long-term care ombudsman (483.15(c)(2) and (3)). Assisted living has no federal equivalent.

**Hypothetical.** E.K., 84, moves into an assisted living community in a state whose rules mirror Florida's chapter 429. It holds a standard license, a wellness nurse checks residents monthly, and aides assist with medications. Pages use the prefixes ALF (facility) and PCP (primary care physician). Everything is invented to show the method.

**E.K.: from move-in to hip fracture** — hypothetical — Illustration
1. Dec 20
**Pre-admission medical exam**
Walks with a walker, transfers independently. Weight 128 lb.

ALF 000012 to 000015
2. Jan 8
**Move-in and service plan**
Standby bathing help, medication assistance. "Independent transfers with walker."

ALF 000020 to 000024
3. Mar 2
**First fall**
Found on bathroom floor at 05:40, no injury. No change to service plan.

Incident report, ALF 000088
4. Mar 15
**Monthly wellness check**
"Unsteady today, encouraged walker use." No weight recorded.

ALF 000097
5. Apr 5
**Doctor's office visit**
Weight 119 lb. Needs help to stand. "Discuss higher level of care with family." No copy in the facility file.

PCP 000044 to 000046
6. Apr 10
**Service plan update**
January text carried forward, including "independent transfers with walker."

ALF 000131
7. Apr 15
**Monthly wellness check missing**
No April entry; March and May exist.

Log, ALF 000095 to 000099
8. Apr 18 to 24
**Aide notes**
"In bed most of day" on 5 of 7 days; "needed 2 staff to get up" on 3 days.

ALF 000140 to 000147
9. Apr 25
**Daughter's email**
Asks about a nursing home. Administrator: "can manage her here with extra help."

ALF 000150 to 000151
10. May 3
**Second fall, hip fracture**
Found on floor at 06:10. Fracture confirmed at the hospital.

ALF 000161; hospital ED record

The decline is documented, but in 3 places: aide notes, the doctor's chart and an email. The service plan, the document meant to track it, never changed.

**Service plan, January** — ALF 000022
Mobility and transfers — Independent transfers with walker. Standby assist for bathing 3 times weekly. Monitoring — Wellness check monthly.
**Service plan, April update** — ALF 000131
Mobility and transfers — Independent transfers with walker. Standby assist for bathing 3 times weekly. Encourage fluids and snacks. Monitoring — Wellness check monthly.
1 line changed, and it addressed weight loss the plan never named. Reviewers call this copy-forward: January's truth reappearing in April.

Plaintiff reading
Apr 5 visit — The doctor flagged a higher level of care; the facility never obtained or acted on it
Apr 10 plan — Copied text shows no real reassessment of continued appropriateness
Apr 18 to 24 — 2-person transfers and days in bed approach the state's bedridden line
Apr 25 email — The family asked; the administrator kept her
Defense reading
Apr 5 visit — The note says "discuss," addressed to the family; the facility was not sent it
Apr 10 plan — Unchanged text reflects her baseline on good days; aides adjusted help day to day
Apr 18 to 24 — She got up with help each day; not "confined to bed" under the statute
Apr 25 email — The statute bars moving her without the family's agreement; they chose to stay
Both readings come from the same pages. The missing April check cuts both ways: the plaintiff calls it the moment a nurse would have seen the decline; the defense notes the license required no nursing assessment.

If you remember one thing
In a "should have been moved" case, the service plan is the spine. Line up every version of it against aide notes, outside physician visits and family messages, and the case theory for either side writes itself.

Chapter 10 Everyone

### Where AI helps and where it fails on long-term care records

A long-term care file is long, repetitive and mixed: EHR printouts, faxed orders, handwritten aide notes, emails and outside charts. In the E.K. hypothetical the deciding facts sat in 3 sources. AI medical record review can line up those facts fast. It cannot decide what they mean.

#### What an LLM does well on these records

A large language model (LLM) reads unstructured text well. A good tool can pull every weight, fall and transfer description into 1 dated list and spot a service plan copied word for word. Clinical NLP, natural language processing tuned to medical text, recognizes that "2 assist" and "needed 2 staff to get up" mean the same thing. An AI medical chronology built this way turns a week of reading into a draft you can check.

#### Where it fails

| Failure | What it looks like in a long-term care file | The human check |
| --- | --- | --- |
| Hallucination | A generative AI summary states a fall "with head strike" that no page records, or invents a physician notification | Open the cited page for every fact you will use; no citation, no use |
| OCR errors on faxes | A faxed order reads 5 mg as 0.5 mg, or a date as 03/18 instead of 08/18 | Check every dose and date on low-confidence pages against the image |
| Missed handwritten notes | Aide flowsheets and incident narratives written by hand are skipped or garbled | Confirm the tool flags pages it could not read; read those yourself |
| Copy-forward text taken as fact | The April service plan's "independent transfers" is reported as April's status | Compare repeated text across versions; trust the dated observation over the template |
| Setting confusion | A summary applies nursing home rules, such as MDS deadlines, to an assisted living resident | Settle which rulebook applies (chapter 2) before any AI output is read as a gap |
| Missing outside records | The chronology looks complete but holds no physician, pharmacy or hospice chart | Build the provider list and request every outside record before trusting the timeline |

2 newer wrinkles. If a facility's clinicians use ambient AI scribes, a signed note may hold text software drafted from a recording; ask which notes and what review policy applied. And agentic AI tools that run multi-step tasks on their own need every step visible, because an early error carries forward.

#### Grounded citations and human-in-the-loop review

The fix for most failures is the same: a page-level citation on every statement, checked by a person. Retrieval-augmented generation (RAG) ties answers to passages from your file, and grounded citations let you verify each line in a click. Human-in-the-loop review means the attorney, legal nurse consultant or expert opens those pages before anything is filed. In *Mata v. Avianca, Inc.*, 678 F. Supp. 3d 443 (S.D.N.Y. 2023), a federal court sanctioned lawyers under Rule 11 for filing a brief with fabricated case citations generated by a chatbot.

#### A vendor checklist for legal AI tools

1 —

##### A citation on every line

Each chronology entry links to the page it came from, with production numbers. Uncited output is a research lead, not evidence.

2 —

##### HIPAA compliant AI, with a signed BAA

A business associate agreement before the first upload, SOC 2, and a written promise not to train models on your data.

3 —

##### Honest OCR on faxes and handwriting

The tool should flag low-confidence pages, not guess quietly. Long-term care files are full of both.

4 —

##### An audit trail of AI use

A log of who uploaded, viewed, edited and exported, so you can answer questions about how the work product was made.

5 —

##### Output you can edit and sign

Findings are drafts for a professional to revise. Avoid tools that present conclusions about negligence or merit.

AI for law firms on either side is a speed tool for reading, never a substitute for judgment. See [HIPAA compliant AI medical record review](https://medrecords.ai/guides/hipaa-compliant-ai-medical-record-review/) and [whether AI is accurate enough for court](https://medrecords.ai/guides/is-ai-accurate-enough-for-court/).

If you remember one thing
Use AI to find and line up the facts, then open every cited page yourself. The output is yours once you rely on it.

Chapter 11 Building

### Templates: 2 request letters and a level-of-care review prompt

Starting points only. Adjust the legal basis to your jurisdiction, request type and the facility's license. Nothing here is legal advice.

##### 1. Assisted living records request

For a state-licensed assisted living community.

[DATE]

[FACILITY NAME], Attn: Administrator / Custodian of Records
[ADDRESS]

Re: [RESIDENT NAME], date of birth [DOB], resident from [MOVE-IN DATE] to [MOVE-OUT DATE]
Basis: [HIPAA authorization / personal representative request / subpoena / discovery request], enclosed

Please produce complete copies of the following for the dates above, in native electronic format where kept electronically:

1. Residency agreement, addenda and every document signed at admission, including any arbitration agreement, with signature pages
2. Medical examination forms, assessments and reassessments
3. Every version of the service plan, with revision dates
4. Medication assistance records, including refused and omitted doses, and the written consent
5. Nurse assessments, wellness checks, aide notes and daily care logs
6. Physician orders and pharmacy records from outside providers
7. Incident reports, investigations, and reports to any state agency
8. Communications with family, physicians, hospice or home health, including emails and texts
9. Move-out notices, staffing schedules for [DATES], and licenses in effect

If any category does not exist, please state so in writing. If any record is withheld, identify it and the reason.

[NAME, FIRM, CONTACT]

##### 2. Nursing home records request

For a certified nursing home. It names records Part 483 requires, so "no such record" becomes a finding.

[DATE]

[FACILITY NAME], Attn: Medical Records / Custodian of Records
[ADDRESS]

Re: [RESIDENT NAME], date of birth [DOB], admitted [DATE], discharged or deceased [DATE]
Basis: [authorization / representative request / subpoena / discovery request], enclosed

Please produce the complete medical record and related records, in native electronic format where kept electronically, including:

1. Admission agreement, any binding arbitration agreement, and proof of the 30-day rescission notice
2. PASARR screening results
3. All MDS 3.0 assessments, with section completion dates and signatures
4. Baseline and every comprehensive care plan, with care conference notes
5. Physician orders, nursing notes, flowsheets and weights
6. MAR and monthly pharmacist reviews with responses
7. Change in condition notices, incident reports and abuse reports to the state
8. Transfer and discharge notices, including the ombudsman copy
9. Posted nurse staffing data for [DATES] and the facility assessment
10. Form CMS-2567 reports for the 3 years before [DATE]
11. Any audit trail or access log for the electronic record

If any category does not exist, please state so in writing.

[NAME, FIRM, CONTACT]

##### 3. Level-of-care review prompt for an AI tool

For a HIPAA compliant AI tool with a signed BAA, run on the full production. Check every cite.

You are organizing records for a review of whether an assisted living resident's needs exceeded the facility's level of care. Do not draw conclusions about negligence, causation or legal standards.

Using only the uploaded records, and citing the page for every statement:

1. List every document that states the resident's mobility, transfer ability, cognition, weight or continence, in date order, quoting the exact words.
2. List every fall, injury, hospital visit or emergency call, with date, time and source page.
3. List every version of the service plan or care plan. For each, show which lines changed from the prior version and which were carried forward word for word.
4. List every outside provider named anywhere in the records (physicians, pharmacies, hospice, home health, hospitals) and whether any record from that provider appears in the production.
5. List every communication from family, physicians or staff that mentions moving the resident, a higher level of care, a nursing home, or hospice.
6. List any period of more than [30] days with no assessment, wellness check or nurse note, if the records show such checks were done at other times.
7. Flag any page you could not read with confidence.

Return tables. If a fact is not in the records, say "not found" instead of guessing.
If you remember one thing
Ask for each record by its name, and ask the facility to say in writing when a category does not exist. That written answer is evidence too.

Chapter 12 Publisher

### What Medrecords AI does with a long-term care file

Medrecords AI is medical chronology software. It works on the records you upload; it does not request or retrieve records from facilities, physicians or state agencies. On a nursing home or assisted living file it does 5 things:

- Builds a [cited chronology](https://medrecords.ai/product/chronology/) across the facility file and every outside chart you add, with [a citation on every line](https://medrecords.ai/product/citations/), so aide notes, physician visits and incident reports land on 1 timeline like the E.K. example in chapter 9.
- Routes faxed orders and handwritten aide notes through [OCR](https://medrecords.ai/product/ocr/) and [handwritten record extraction](https://medrecords.ai/product/handwritten-medical-record-extraction/), and flags low-confidence pages for a human read.
- [Flags records the file implies but does not contain](https://medrecords.ai/product/missing-records-identification/), such as a month missing from a monthly log, or an outside physician visit that the facility file mentions with no note produced. Each flag cites the page that implies it.
- Shows [near-duplicate pages that differ](https://medrecords.ai/product/record-alteration-detection/) side by side, which surfaces copied service plans and care plans where only a line or 2 changed.
- Extracts a [provider list](https://medrecords.ai/product/provider-list-extraction/) from the file, so you can see which outside charts you still need, and compares later productions against the existing file through [supplemental record review](https://medrecords.ai/product/supplemental-record-review/).

What it does not do: it does not decide which state's rules apply, whether a resident should have been moved, whether staffing was sufficient, or whether an arbitration agreement is enforceable. It does not score cases or give legal advice. Flags are signals, not verdicts. It runs under SOC 2 and HIPAA with a signed BAA (see [security](https://medrecords.ai/security/) and [HIPAA](https://medrecords.ai/hipaa/) ). Self-Service bills 10 cents a deduplicated page, down to 5 cents at volume, duplicates free; Enterprise On-Prem is an annual license. More on the use case: [nursing home neglect record review](https://medrecords.ai/solutions/nursing-home-neglect-record-review/).

The offer

#### See a cited long-term care timeline built from your own file.

Book a demo on a nursing home or assisted living file you are working, then run your first case free on us. Every line comes back cited to its source page. You review, you revise, you sign.

[Book a demo](https://medrecords.ai/demo/) [See the cited chronology](https://medrecords.ai/product/chronology/)
Scheduling only. No records move from a public page.

Chapter 13 Everyone

### Frequently asked questions

What is the main difference between assisted living and a nursing home?A nursing home provides 24-hour nursing care and, if it takes Medicare or Medicaid, must meet 42 CFR Part 483. Assisted living provides housing, meals and help with daily activities under a state license, with no federal operating standard.
Do assisted living facilities have to follow federal nursing home rules?No. Assisted living follows state licensing law. If Medicaid pays through a home and community-based waiver, the HCBS settings rule at 42 CFR 441.301(c) also applies.
Does assisted living use the MDS?No. The MDS is the federal assessment for certified nursing homes. Assisted living uses a state assessment form or the facility's own, on whatever schedule the state sets.
Is the 2024 nursing home minimum staffing rule in effect?No. 2 federal courts vacated its core provisions in 2025, Public Law 119-21 barred enforcement until after September 30, 2034, and CMS repealed them effective February 2, 2026. The federal rule now requires sufficient staff and an RN 8 consecutive hours a day, 7 days a week.
Can a nursing home make me sign an arbitration agreement to get in?Not a certified one. Under 42 CFR 483.70(m) a facility may not require an arbitration agreement as a condition of admission or continued care, and the resident may rescind within 30 calendar days of signing. Assisted living contracts are not covered by that rule; state contract law and the Federal Arbitration Act apply.
Where can I find inspection reports for a nursing home or assisted living facility?For certified nursing homes, the Form CMS-2567 is posted in the facility, public within 14 calendar days after the facility receives it, and shown on CMS's Care Compare site. For assisted living, check the state licensing agency or file a public records request.
Is it HIPAA compliant to upload nursing home records to an AI tool?It can be, if the vendor signs a business associate agreement, holds SOC 2, does not train on your data and logs access. A consumer chatbot with no BAA is the wrong place for a resident's records.
Can ChatGPT summarize nursing home or assisted living records for a lawsuit?A general chatbot can summarize text you paste, but it gives no page citations and can invent facts such as dates or falls. For litigation, use a tool that cites every line to its source page, and check each cite before you rely on it.
Can AI decide whether an assisted living resident should have been moved to a nursing home?No. Software can line up every assessment, fall, weight and family message with page citations. Whether the facility met its duty under state law is a question for the lawyers, experts and the court.
What records prove a resident needed a higher level of care?Usually a combination: every service plan version, aide notes, incident reports, nurse logs, outside physician notes, pharmacy and hospice records, and family messages. The outside records are often missed.

Chapter 14 Everyone

### Sources and method

Regulations were read in their eCFR text in September 2026. The staffing rule's history comes from the CMS repeal rule, which reports the court decisions and the statute; the Texas decision date comes from the opinion itself; the outcome of the Fifth Circuit appeal the rule mentions was not verified. Florida statutes are the 2025 text, used only as an example. The E.K. timeline, medication record and service plan comparison are hypothetical. Nothing here is legal or medical advice.

- [42 CFR Part 483](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483): 483.1 (basis and scope), 483.10(g) (records access, survey results, notification), 483.12 (restraints, abuse reporting), 483.15(c) (transfer and discharge), 483.20 (MDS timing and accuracy), 483.21 (care plans), 483.30(c) (physician visits), 483.45(c) (pharmacist review), 483.70(h), (m) and (p) (records, arbitration, staffing data), 483.71 (facility assessment).
- [42 CFR 483.35](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.35), nursing services, as amended at 90 FR 55697 (December 3, 2025).
- [CMS-3442-IFC](https://www.federalregister.gov/documents/2025/12/03/2025-21792/medicare-and-medicaid-programs-repeal-of-minimum-staffing-standards-for-long-term-care-facilities), repeal of minimum staffing standards, effective February 2, 2026.
- [CMS-3342-F](https://www.federalregister.gov/documents/2019/07/18/2019-14945/medicare-and-medicaid-programs-revision-of-requirements-for-long-term-care-facilities-arbitration), 2019 arbitration final rule, including the history of the 2016 ban and injunction.
- [42 CFR 441.301(c)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-441/subpart-G/section-441.301), person-centered service plans and HCBS settings requirements.
- [42 USC 1395i-3](https://www.law.cornell.edu/uscode/text/42/1395i-3), subsection (g): survey intervals, special surveys, public disclosure of deficiencies.
- [9 USC 2](https://www.law.cornell.edu/uscode/text/9/2), Federal Arbitration Act.
- [45 CFR 160.103](https://www.law.cornell.edu/cfr/text/45/160.103) (covered entity) and [45 CFR 164.524](https://www.law.cornell.edu/cfr/text/45/164.524) (access, 30 days).
- [CMS State Operations Manual, Appendix PP](https://www.cms.gov/medicare/provider-enrollment-and-certification/guidanceforlawsandregulations/downloads/appendix-pp-state-operations-manual.pdf): F580, F609, F636, F641, F656, F689, F725, F842, F847, F848, F851, and the meaning of "results of the most recent survey."
- [MDS 3.0 RAI Manual, version 1.20.1](https://www.cms.gov/files/document/final-mds-3-0-rai-manual-v1-20-1-october-2025.pdf) (October 2025): section list. Version 1.20.11 takes effect October 1, 2026.
- [GAO-19-599](https://www.gao.gov/products/gao-19-599) (2019): no federal abuse reporting and investigation requirements for assisted living comparable to those for nursing homes; state Medicaid agency abuse reporting policies.
- [GAO-26-107884](https://www.gao.gov/products/gao-26-107884) (2026): 44 states covering assisted living services under Medicaid as of March 2025, 29 through waivers (GAO counts the District of Columbia as a state); at least $12 billion in 2024 federal spending, $8.5 billion traditional Medicare and at least $3.5 billion federal Medicaid.
- CDC NCHS FastStats: [nursing home care](https://www.cdc.gov/nchs/fastats/nursing-home-care.htm) and [residential care communities](https://www.cdc.gov/nchs/fastats/residential-care-communities.htm), 2022.
- Florida Statutes (2025): [429.02](https://www.flsenate.gov/Laws/Statutes/2025/429.02), [429.26](https://www.flsenate.gov/Laws/Statutes/2025/429.26), [429.256](https://www.flsenate.gov/Laws/Statutes/2025/429.256).
- *Mata v. Avianca, Inc.*, 678 F. Supp. 3d 443 (S.D.N.Y. 2023): Rule 11 sanctions for fabricated AI-generated citations.

Related guides: [nursing home records, the MDS and CMS-2567](https://medrecords.ai/guides/nursing-home-records-mds-cms-2567/), [change in condition records](https://medrecords.ai/guides/nursing-home-change-in-condition/), [nursing home fall lawsuit records](https://medrecords.ai/guides/nursing-home-fall-lawsuit-records/), and [elder abuse and financial exploitation records](https://medrecords.ai/guides/elder-abuse-financial-exploitation-records/).

### More guides

- [**Bedsore lawsuit records: how pressure injury cases are proven and defended** — The records that decide a bedsore lawsuit: NPIAP staging, F686 avoidability, Braden scores, turning logs, wound…](https://medrecords.ai/guides/pressure-injury-bedsore-lawsuit-records/)
- [**Blunt force trauma: how the injuries are classified, documented and used in court** — Blunt force trauma explained: abrasions, contusions, lacerations and fractures, how ER and forensic records…](https://medrecords.ai/guides/blunt-force-trauma-medical-records/)
- [**Can AI read DICOM imaging, not just the report?** — How AI reads full MRI, CT, and X-ray studies as native DICOM: a browser PACS viewer, 3D reconstruction…](https://medrecords.ai/guides/can-ai-read-dicom-imaging/)
- [**Can AI read handwritten medical records?** — Context-aware AI reads cursive notes, intake forms, and margin annotations into cited, structured fields, and…](https://medrecords.ai/guides/can-ai-read-handwritten-medical-records/)
- [**Charting by exception: how to read WDL entries and blank flowsheet cells in a nursing negligence case** — Charting by exception in nursing negligence cases: what WDL and a blank flowsheet cell mean, Lama v. Borras…](https://medrecords.ai/guides/charting-by-exception/)
- [**Child abuse medical records: sentinel injuries, abusive head trauma and the workup** — How to read child abuse medical records: sentinel injuries, TEN-4-FACESp, the skeletal survey, the abusive head…](https://medrecords.ai/guides/child-abuse-medical-records/)