Methodology · State regulated
Assisted Living Facilities, Memory Care communities, and Residential Care Homes are licensed and inspected by states, not the federal government. What the public can learn about them depends almost entirely on what each state chooses to disclose.
Most older adults in the United States who need help with daily activities — bathing, dressing, medication management — live in state-licensed settings: Assisted Living Facilities (ALFs), Board and Care homes, Memory Care units, or Continuing Care Retirement Communities (CCRCs). These settings are not certified under Medicare or Medicaid (unless they also have a certified SNF wing), so they do not report to CMS and are not included in Care Compare.
Each state writes its own licensing standards, sets its own inspection frequency, employs its own surveyors, and decides what to publish. There is no federal floor for disclosure. The result is a patchwork that makes it genuinely difficult to compare facilities across state lines — or even to know basic facts like how often a facility has been inspected.
Some states inspect ALFs annually. Others inspect on a complaint-only basis, meaning facilities can go years without a routine survey. The federal rule requiring SNFs to be inspected at least once every 15 months does not apply to state-licensed facilities.
Minimum staffing ratios, required training hours for aides, and nurse delegation authority all vary by state. There is no PBJ-equivalent for ALFs — no state requires the kind of payroll-level staffing reporting that CMS mandates for SNFs.
States differ significantly in what level of care ALFs are permitted to provide. Some states allow ALFs to retain residents with advanced dementia or who require nursing care. Others require transfer to a nursing home at a lower acuity threshold. The acuity limit determines who is actually living in an ALF — which matters for understanding what inspections are measuring.
Some states post full inspection reports online, including deficiency details comparable to what CMS publishes for SNFs. Others post only a license status and a renewal date. Most fall somewhere between.
This is a simplified representation of the ALF disclosure landscape as of our most recent review. Disclosure practices change — states have improved and regressed. See our data availability page for a more detailed state-by-state breakdown.
Higher disclosure
Publishes ALF inspection reports or complaint summaries online. Some publish deficiency data comparable in depth to CMS (though not with the same standardization).
Partial disclosure
Some inspection or complaint data is available, but it may require a public records request, be available only for recent years, or lack the deficiency detail of federal records.
Limited or no public disclosure
Little or no online-accessible inspection or complaint data for ALFs. Families must contact the state licensing agency directly — and outcomes vary widely.
For facilities that are purely state-licensed (no federal CCN), we show:
We do not apply a Trust Index score or CMS star rating to state-regulated facilities because the underlying data does not support it. Displaying a score where we lack the inputs would be misleading.
Any long-term care facility that is licensed by a state agency rather than federally certified by CMS. The most common are assisted living facilities (ALFs), residential care facilities (RCFs / RCFEs), board and care homes, and personal care homes. Each state defines and regulates them differently.
Because ALFs do not bill Medicare for skilled nursing care, they sit outside the federal certification system that produces the CMS Five-Star ratings. The result is 50 different state regulatory regimes with very different transparency.
California, Florida, Texas, New York, and a handful of others publish full or partial inspection records online. Many states publish nothing — see the data availability map for the full breakdown.
Where state inspection data is public we surface it directly. Where it isn't, we say so explicitly with a Data Desert notice — we do not generate fake scores from sparse data.
Three things: (1) Call your state long-term care ombudsman — every state has one and complaint history is often available by phone; (2) ask the facility for their last two years of state inspection reports; (3) check the state Medicaid agency for any quality reports tied to Medicaid waiver participation.