‘A slap on the wrist’: families and advocates call for increased accountability from assisted living facilities 

By Grace Vitaglione

This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations and The Silver Century Foundation.

Kristin Goforth and Lauren Cox, twin sisters aged 49, moved their father into a Piedmont Triad-area assisted living facility on March 13, 2021. Rick Goforth, then 75, was in good health; he was an avid walker who enjoyed being outside. But he was exhibiting signs of dementia — he had wandered off twice — so they decided a facility specializing in memory care would be safest.

He entered the facility at the lowest level of care available, passing all the assessments for activities of daily living such as independent bathing and eating.

Two months later, Rick was dead.

The sisters said they watched their father undergo a “drastic” decline in the facility; days after his arrival, he fell and broke his wrist. It turns out facility staff were giving Rick medicines the family hadn’t known about, including administering his usual dose of Xanax three times a day instead of his prior regimen of only once a day. Plus, he was getting extra “as-needed” doses. 

Because of the broken wrist, he lost the ability to use a knife and fork, nonetheless the staff didn’t cut up his food for him, Kristin said. 

Rick started falling repeatedly and staff put him in a wheelchair against a wall, with a table blocking him from moving.

Near the end of April, the family took him to the hospital – he was severely dehydrated, malnourished and in acute renal failure — “basically hospice-ready,” Cox said. 

Rick died a couple weeks later.

The sisters had difficulty finding justice for their father’s death. First, the family called the county department of social services, which said they didn’t find anything wrong at the facility. Then they complained to the state, which found the facility had violated regulations resulting in death or serious physical harm, abuse, neglect or exploitation of a resident. Eventually, the state fined the facility $19,000.

Cox called that “a slap on the wrist.” The family sued the facility and came to a settlement subject to a confidentiality agreement that limits Cox from being able to say more. 

Advocates say Goforth’s story is an example of how the regulations overseeing assisted living facilities in North Carolina can be out of date, and public officials’ enforcement of those regulations can vary from county to county.  

When officials do fine facilities for violations, facilities have the ability to negotiate those penalties down to very little, advocates said. A NC Health News analysis found that fewer than half of penalties levied in the last three years were paid in full by facilities. 

Assisted living over time

In North Carolina, assisted living facilities are referred to as “adult care homes” or “family care homes.” There are more than 1,200 of these facilities in the state, according to the North Carolina Department of Health and Human Services, and they can range in size from family care homes — licensed to have two to six residents — to larger adult care homes licensed to have more, with some housing more than 100 residents. 

Residents of these homes may need help with activities of daily living, such as eating, dressing and bathing. They may require 24-hour supervision, but they don’t need regular nursing care. These residents are supposed to have less-complex health needs than those in skilled nursing facilities, or nursing homes, where residents’ needs require regular medical intervention.

The severity of patients’ conditions in adult care homes has become more profound over the years, said Mary Bethel, board chair of the NC Coalition on Aging. People who in the past would have been placed in a nursing home now live in adult care homes, she said.

In recent decades, adult care homes were also the destination for many former psychiatric hospital patients when the state undertook a process of deinstitutionalization for people living in them, said Hillary Kaylor, an ombudsman who advocates for residents in long-term care in Mecklenburg and eight surrounding counties.

Many of the facilities weren’t prepared to take on that mental health population and weren’t given support to do so, she said.

“We over-built [the industry], we under-supported, and then we expected a lot,” she said.

Eventually, North Carolina’s overreliance on adult care homes to house psychiatric patients led to a settlement with the U.S. Department of Justice over improper institutionalization of mental health patients in violation of the Americans with Disabilities Act and the subsequent Supreme Court Olmstead decision. 

‘Working with an old book’

Adult care homes are regulated primarily at the state and county level, whereas most nursing homes, which can receive Medicare payments, have to follow federal rules as well.

Kaylor said oftentimes, the rules for care in an adult care home are set by a contract between family members and/or residents and the facility, so the levels of care can vary. Some facilities may have a registered nurse there eight hours a day, and some may have one that only visits twice a week, for example, she said.

But as patients’ conditions in adult care homes become more severe, Kaylor said that might call for updated regulations to accommodate those changes.

“Sometimes we’re working with an old book,” she said.

There is an enhanced license associated with having a special care unit, or a secure wing specifically for dementia patients, said Elizabeth Todd, lawyer for the Goforth family. Her practice focuses on nursing home and assisted living negligence. 

Facilities must apply for the enhanced license, which comes with higher staffing and training requirements. But some facilities can get around those rules by calling their dementia wing a “memory care unit” and just locking the door, she said. 

In adult care homes, most of the regulations are pretty generic, Todd said.

In contrast, “there’s a regulation for everything in a skilled nursing facility,” she said. “I don’t want to call it the wild west in adult care homes, but it’s not far off.”

The rules governing adult care homes have to be “readopted” every 10 years; the most recent round was completed in 2025, according to a NC DHHS spokesperson. Many areas were strengthened in the last few years, including infection prevention and control, emergency preparedness, administrator and management requirements, and resident discharge requirements.

Jeff Horton, executive director of the NC Senior Living Association, an advocacy organization for adult and care homes, said regulations have become much more stringent over the last couple decades to keep up with acuity levels.

For instance, positions such as medication aides and personal care aides have to undergo a certain amount of training, he said.

If the state were to increase requirements, such as requiring adult care homes to have registered nurses on staff, then the state should also increase reimbursements to facilities that receive public funds, Horton said.

Vacancies and turnover at the state level

Adult care homes are monitored by county departments of social services and the NC Division of Health Service Regulation through complaint investigations and annual surveys.

The state regulatory division had a 25 percent vacancy rate in March 2025 and a turnover rate of 11 percent in 2024, according to a NC DHHS spokesperson. In the past two years, that turnover rate was even higher.

Former Gov. Roy Cooper’s last four recommended budgets included additional positions for adult care surveyor positions, but the NC General Assembly didn’t put funds for additional inspectors into any of their final budgets.

Complaints to the state about adult care homes and family care homes have also increased, the spokesperson said. From 2020 to 2024, complaints rose over 22 percent.

At the county level, regulation can vary depending on resources, Kaylor said. For example, Mecklenburg County has staffers focused solely on adult care homes, but in more rural counties, social services staffers end up stretched thin.

Adult care homes in the eastern part of the state have complained they face stricter enforcement than those in the west, according to Horton. County social services staff in the east tend to be more aggressive and levy fines more readily, association members have told him.

New Hanover County Social Services Director Tonya Jackson said in a statement over email that the team works with staff from the state Division of Health Service Regulation to make sure all complaints are investigated and addressed promptly.

“Additionally, county staff participates in standardized state training each year to ensure a full understanding of rules and regulations,” she said.

The state division gives the same training to all county social services staffers who monitor adult care homes, said a DHHS spokesperson, and the state can provide technical assistance as needed. Situations can vary in each facility, so enforcement happens differently according to each specific place, the spokesperson said.

Inconsistent enforcement

Bill Lamb, a longtime advocate for seniors, sits on the board of directors of the advocacy nonprofit Friends of Residents in Long Term Care. He said the wide variation in penalties and citations across the state shows that enforcement is inconsistent. 

Lawsuits like the one pursued by the Goforth family are sometimes the only way to hold a facility accountable, Lamb said.

Yet even then, some facilities have clauses in their contracts that require residents or family members to agree to settling disputes through arbitration rather than in court. When a consumer signs admission papers for themselves or a loved one into a facility home, these clauses are often tucked among the dozens of pages of legalese in the contract. 

Such provisions eliminate the opportunity for a consumer who ends up in conflict with a nursing home to go to court. Plaintiffs often win less money in these types of cases, Todd said.

State lawmakers have also enacted a cap on noneconomic damages, such as compensation for pain and suffering, for medical malpractice in North Carolina. Those are usually the primary type of damages in a case against an assisted living facility, Todd said. 

That cap can make it harder for plaintiffs to find a lawyer who will take the case, which can take months or even years to pursue. Lawyers often are paid a percentage of the damages as payment, she said.

“The caps on damages is unjust primarily because there is absolutely no limit to the amount of damage these facilities can do, but there is a limit to what they have to pay for having killed people,” Todd said.

‘A leaky bucket’

When state or county inspectors find that an adult care home violated a regulation, they can levy a penalty. If facility administrators disagree with that finding, they can appeal through an Informal Dispute Resolution or go to the state Office of Administrative Hearings. 

Fewer than half of the penalties levied against adult care homes in the past three years were paid in full, according to records from the N.C. Division of Health Service Regulation analyzed by NC Health News. Around 26 percent of the penalties were settled with the state, 11 percent were not paid and referred to the Office of the Controller, 13 percent were in the appeal process and 4 percent were blank.

Lamb said those numbers showed a lack of full accountability.

“That’s a pretty leaky bucket if you ask me,” he said.

Wealthier chains of adult care homes can “lawyer up” and drag out the appeal process, Lamb said, sometimes for years.

Using penalties effectively 

The maximum penalty for a violation resulting in death or serious physical harm, abuse, neglect, or exploitation to a resident is $20,000 for an adult care home, licensed for seven or more residents. The facility can then be fined up to $1,000 each day the violation remains unaddressed.

“That’s what a life is worth in our state,” Lamb said. 

Horton was previously a nursing home regulator, and he said there are times when regulators get things wrong — that’s why it’s important to have an appeals system. A settlement isn’t always bad, either, he said, as sometimes that means the penalty is waived in lieu of extra staff training.

Training can make more of a difference towards improving outcomes than a penalty, Horton said. Penalty dollars don’t flow back into any part of the long-term care system, though. They are designated — by law — to support the local school district.

While penalties can be a deterrent for breaking the rules, Horton said it’s important to look at the end goal of what they achieve in terms of improving care.

If the facility demonstrates a pattern of breaking the rules, state surveyors can suspend admissions, as well as downgrade, revoke or suspend their license, according to NC DHHS. If the facility has outstanding unpaid fees, the department will not issue them a new license or renew their license.

Despite her family’s settlement with her father’s facility, Kristin Goforth said she still doesn’t feel good about the situation — there should be better protections for older people. Lauren Cox said there should be more accountability for facilities overall.

“This can’t be the way we treat people who have spent their entire life contributing to society…they work, they pay their taxes, they do everything right, and then at their end of life, we do this?” Cox said.

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