Just 1 in 24 elder abuse cases is ever reported to authorities, as researchers uncover a system-wide failure to protect vulnerable residents
A comprehensive new study from The Schiller Kessler Group of federal nursing home inspection data has found that more than a third of America’s nursing homes, 36.5%, received at least one federal citation for abuse, neglect, or exploitation during their most recent government inspection, exposing what researchers describe as a widespread and largely unreported crisis in elder care.
The study, based on Centers for Medicare and Medicaid Services (CMS) data covering 14,689 facilities across all 50 states and Washington, D.C., found that federal inspectors issued 10,493 abuse-related citations during the most recent inspection cycle, with survey dates spanning from late 2019 through March 2026. Looking across the full study period, a total of 31,068 citations were issued against 9,651 residential facilities nationwide.
“Millions of elderly Americans suffer from abuse, neglect, or exploitation in nursing homes each year, yet only 1 in 24 elder abuse cases is ever formally reported,” said a spokesperson for Injured in Florida, which conducted the research. “That gap between what’s happening and what’s documented is the real story here.”
Complaints, not inspections, are catching most abuse
Perhaps the study’s most striking finding is that nearly 7 in 10 citations, 69.4%, were triggered by resident or family complaints rather than routine government oversight. That means the majority of documented abuse only came to light because someone directly affected spoke up, not because regulators proactively identified a problem.
Of all citations issued, 1,328, or 12.7%, involved documented actual harm or immediate jeopardy to residents, the most serious classifications used by federal inspectors. These findings indicate that inspectors found evidence of real, measurable harm or an imminent threat to resident safety at the time of their visit, not merely a paperwork or procedural failure.
Financial penalties haven’t stopped repeat violations
Despite the scale of documented abuse, the study found accountability has been inconsistent. Between April 2023 and March 2026, nursing home operators paid more than $467 million in fines across over 6,600 facilities, and an additional 1,949 facilities faced Medicare and Medicaid payment blocks.
Yet nearly 1 in 11 facilities, 8.8%, received three or more separate abuse citations within a single inspection cycle, raising serious questions about whether financial penalties are large enough to change facility behavior. The study notes that spreading the $467 million in fines across all cited facilities produces an average penalty of roughly $70,800, a sum researchers describe as a manageable operating cost for facilities that typically generate well over $10 million in annual revenue.
The most common violations reveal a pattern
The study’s breakdown of citation types found that the two leading violation categories, each accounting for 27% of all citations, were a failure to protect residents from physical, mental, or sexual abuse and a failure to properly report suspected abuse or neglect to authorities. A third major category, failure to adequately investigate abuse allegations once reported, accounted for a further 17.2% of citations. Combined, these three failures, to protect, to report, and to investigate, made up 71.2% of all citations issued nationwide.
Other significant violation categories included improper use of psychotropic medications and chemical restraints (883 citations), failure to establish written abuse prevention policies (854 citations), financial exploitation (522 citations), and improper use of physical restraints (502 citations).
A reporting gap hides the true scale of the problem
The study’s authors emphasize that official CMS citation data likely captures only a fraction of actual nursing home abuse nationwide. Because routine inspections uncovered less than a third of all documented violations, and because many nursing home residents are physically or cognitively unable to report mistreatment themselves, researchers say the true scope of elder abuse in American nursing homes is almost certainly far greater than official figures suggest.
Research cited in the study found that between 10% and 20% of nursing home residents experience some form of abuse each year. Staffing shortages compound the risk: in 2024, 72% of nursing homes were operating below pre-pandemic staffing levels, a factor researchers link to increased incidents of resident-on-resident abuse in understaffed facilities.
The study calls for two major reforms: more rigorous, proactive federal oversight of chronically underperforming facilities, and financial and regulatory deterrents substantial enough to actually change facility behavior rather than functioning as a routine cost of doing business.