Washington, D.C. posted the highest rate of nursing home abuse citations of any U.S. jurisdiction, with 94.1% of its facilities, 16 of 17 total, cited for abuse, neglect, or exploitation during their most recent federal inspection, according to a new state-by-state analysis from The Schiller Kessler Group of nursing home citation data. The finding is part of a broader report that ranks states not by raw citation counts, which tend to favor large states like California by sheer volume, but by the proportion of each state’s facilities carrying a documented federal violation, a method the report’s authors say offers a far clearer picture of where elder care oversight is actually failing.
Montana ranked second, with 65.6% of its facilities, 40 of 61, cited, followed closely by Maryland at 65.2%, or 144 of 221 nursing homes. The report notes that despite vast differences in geography, population density, and healthcare infrastructure between a small rural state like Montana and a densely populated state like Maryland, both post strikingly similar citation rates, suggesting the underlying drivers of abuse citations, chiefly staffing, management, and oversight failures, cut across regional and demographic lines rather than being confined to any one type of state.
Washington state ranked fourth at 61.9%, followed by Wyoming at 61.1% (22 of 36 facilities cited), Delaware at 59.1%, Connecticut at 58.6%, Arizona at 57.1%, Oregon at 53.1%, and Illinois at 51.7%, rounding out the ten states with the highest proportion of cited facilities. The report’s authors emphasize the diversity among these states, spanning tiny jurisdictions like Washington, D.C. to states with hundreds of facilities like Illinois, and rural states like Montana and Wyoming alongside dense urban and suburban states like Maryland and Connecticut, as evidence that nursing home abuse is not a regional problem but a nationwide structural one.
Florida stands out as a notable exception to that trend. Despite being home to 694 nursing homes, one of the largest facility counts of any state, and one of the oldest, fastest-growing senior populations in the country, Florida ranked just 46th out of 51 jurisdictions when measured by the proportion of facilities cited. Only 19.3% of Florida’s nursing homes, 134 of 694, received a federal abuse citation during their most recent inspection cycle, amounting to 201 total citations, an average of just 0.29 citations per facility, well below the national average of 0.72. Only five states posted a lower percentage of cited facilities than Florida: Kentucky (17.9%), Alabama (18.8%), South Carolina and New Hampshire (both 20.3%), and Arkansas (12.7%).
The report’s authors caution against reading Florida’s relatively strong proportional ranking as evidence the state has solved the underlying problem, noting that even a comparatively low citation rate still translates to more than 130 individual facilities with a documented federal abuse violation on record, in a state whose elderly population continues to grow faster than almost anywhere else in the country.
The financial accountability system applied across all of these states, the report finds, does not currently distinguish between a facility in a state like Washington, D.C., where 94.1% of homes carry a citation, and a facility in a state like Arkansas, where just 12.7% do. Nor does it distinguish between a facility’s first citation and its fifth. Each violation, regardless of a state’s broader pattern or a facility’s citation history, is generally penalized as an isolated incident.
The report’s authors note that these citation rates almost certainly understate the true scope of the problem in every state examined, including Florida. Nationally, researchers estimate roughly 5 million elder abuse cases occur each year across all care settings, yet only 1 in 24 is ever formally reported, meaning even states with comparatively strong proportional rankings likely have far more undocumented cases than their citation counts alone would suggest.
“The data shows a system that documents failure after failure but rarely follows through with consequences that actually change behavior,” said an attorney with the legal team behind the report. “Where a facility sits on this map shouldn’t determine how seriously its violations are treated.”
