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| Veronica Finkelstein |
Premiering in August, Amazon's three-part docuseries on nursing home abuse, "No Country for Old People," laid bare the systemic failures of nursing homes across the country, exposing patterns of neglect, abuse and institutional indifference.
Recent headlines have demonstrated that what is shown in the docuseries is not an isolated occurrence. These headlines have spotlighted alarming cases of nursing home abuse across the U.S., including an Aug. 25 $12 million settlement against the Van Duyn Center for Rehabilitation and Nursing in New York for systemic neglect and fraud, and criminal charges filed on July 31 against two Pittsburgh-area employees, Joseph Love and Lamont Mitchell, who were allegedly caught on video physically abusing an elderly man.[1]
And just last week, in Keeler v. Rosewood Operator LLC, a Missouri woman filed suit in Jackson County Circuit Court alleging that assisted living facility The Groves' neglect led to her father's death.
These cases underscore persistent gaps in oversight, accountability and protection for vulnerable residents in long-term care.
A 2022 U.S. Department of Health and Human Services study found that 56% of Americans turning 65 today will develop a disability serious enough to require long-term services and supports.[2] In other words, if we live long enough, many of us will be a resident, have a family member or loved one who is a resident, or be a caregiver for a person who is a resident in a nursing home.
So why hasn't more been done to address these pervasive abuses?
The answer isn't a lack of legal tools.[3] It is the nearly insurmountable challenges of using them effectively to change future action. Prosecuting nursing home abuse, whether criminally or civilly, is legally viable but practically daunting.[4] Victims can be frail — sometimes too frail to testify.[5] Evidence is elusive. Facilities are protected by layers of bureaucracy and corporate insulation.
Three Challenges
The challenges are multifaceted, but three are primary.
1. The Nature of the Victims
Most nursing home residents are elderly, though an estimated 17% are residents with disabilities who are under age 65.[6] An elderly or disabled nursing home resident is likely to have difficulty finding an attorney willing to take on their civil claim because it lacks the economic damages that are a mainstay of most other tort cases — medical expenses and lost wages.[7]
Moreover, since the medical expenses of most nursing home residents are paid by public funds, any recovery can be significantly reduced to satisfy Medicare and Medicaid liens.[8]
In addition, many nursing home residents live with cognitive impairments like dementia.[9] These conditions can complicate every step of the legal process: reporting abuse, recalling events, testifying credibly, etc.
In both criminal and civil cases, the absence of reliable direct testimony can be fatal to a case. Prosecutors, already stretched thin, may decline to pursue cases they view as unwinnable.[10] And in civil litigation, the reality is often just as grim. Cases settle early and for modest sums — not because the harm was minor, but because everyone involved understands the case is unlikely to survive trial. The evidentiary gaps are simply too wide.[11]
Even when elderly witnesses are willing to testify, their credibility is often unfairly scrutinized.[12] Cognitive impairments, hearing loss and memory lapses are common features of aging, and these could cast doubt on the reliability of a victim's account. Judges and juries may struggle to reconcile the emotional weight of the testimony with perceived inconsistencies in detail or chronology.[13]
This dynamic can not only undermine the case, but also reinforce a broader cultural bias that devalues the voices of older adults.
2. Institutional Barriers
The second challenge is structural. Many nursing homes are owned by sprawling corporate entities with convoluted ownership schemes.[14] Legal responsibility is diffused across subsidiaries, contractors and shell companies.[15]
Staffing, medical care and administration are often outsourced, which can create layers of plausible deniability.[16] Records may be incomplete or inaccessible. Regulatory agencies, tasked with oversight, are underfunded and slow to act.[17] And arbitration clauses in nursing home care agreements may bar direct access to the courts.[18]
Families and prosecutors are left to navigate a system that can frustrate accountability.
For criminal prosecutors, these institutional hurdles compound the evidentiary ones. Proving guilt beyond a reasonable doubt is difficult when victims cannot testify and physical evidence is ambiguous. Even when injuries — such as bruises, bedsores or unexplained fractures — are documented, establishing intent or identifying the responsible party is rarely straightforward.
Staff turnover is high. Witnesses fear retaliation. With limited resources, prosecutors may walk away from cases that, while morally compelling, are legally difficult.[19]
Civil cases face their own headwinds. Corporations and private equity firms often operate individual nursing homes through stand-alone subsidiaries that have no control over finances and operational policy — because that control rests with the parent company — making it difficult for plaintiffs to collect judgments because the nursing home lacks sufficient assets.[20]
And even when a plaintiff successfully obtains a substantial judgment, collection can be stymied by bankruptcy. For example, public reporting from 2022 suggests that Consulate Health Care, owner of 140 nursing homes nationwide, filed for bankruptcy protection during settlement proceedings, after which numerous plaintiffs and their families accepted substantially reduced settlements.[21]
According to reports, this was part of a broader pattern in which Consulate's complex corporate structure and minimal liability coverage made it difficult for victims to hold the company accountable.[22]
And even if there are financial resources to pay a judgment, plaintiffs must still prove causation and damages, often with vague medical records and contested expert testimony. Defense counsel may argue that any injuries stem from preexisting conditions or from the natural decline of aging. Liability may shift to low-level employees with little ability to pay any verdict.[23] Juries may be sympathetic, but they are also vulnerable to narratives that frame abuse as an unfortunate but inevitable part of elder care.
The result is modest settlements, limited deterrence and little systemic change.[24]
3. Cultural and Psychological Barriers
The third challenge is harder to quantify, but no less real. Cultural and psychological forces discourage reporting and litigation.[25] Elder abuse in institutional settings is often cloaked in silence, not just because victims may be unable to speak out, but because families, caregivers and professionals may hesitate to act.
Shame, guilt and denial are powerful deterrents.[26] No one wants to admit they missed the signs of abuse or neglect. Residents may fear retaliation.[27] Staff may rationalize neglect as the unavoidable consequence of understaffing or burnout.[28] And administrators may actively suppress complaints to protect the facility's reputation. The result is a system that disincentivizes reporting and prompt action.
This silence is reinforced by societal attitudes toward aging.[29] In many communities, older adults are marginalized. Their suffering is minimized. Abuse and neglect are reframed as poor care or isolated incidents, rather than systemic failures. Families may avoid legal action out of fear. This can include fear of retaliation, fear of public exposure and fear of the emotional toll.
These biases extend into the courtroom. Jurors may struggle to connect with elderly victims, especially those with dementia or limited communication abilities. They may unconsciously devalue the harm, viewing the victim's life as nearing its natural end anyway. Defense counsel may argue that the abuse did not meaningfully alter the victim's quality of life.[30] Judges may be similarly affected, leading to lower damage awards or a reluctance to sanction facilities harshly.
Potential Reforms
To make nursing home abuse cases more viable in the U.S., a comprehensive overhaul of regulatory, legal and financial structures is urgently needed.
At the forefront is the need for stronger federal oversight and enforcement mechanisms to ensure that facilities are held accountable for substandard care. The current system often relies on state-level inspections and penalties, which vary widely in rigor and effectiveness.[31] As a result, facilities with repeated violations may continue operating with minimal consequences.[32]
A more standardized federal system for oversight would help address the gaps in this state-by-state patchwork.
A central driver of abuse and neglect is chronic understaffing, which leaves caregivers overwhelmed and residents vulnerable.[33] Last April, the Centers for Medicare & Medicaid Services proposed a federal rule that would address this by requiring a registered nurse to be on-site 24/7, and mandate staff-to-resident ratios based on facility size and acuity levels.[34]
But this April, the U.S. District Court for the Northern District of Texas struck down the rule in American Health Care Association v. Kennedy.
These staffing standards are critical not only for preventing abuse, but also for enabling timely intervention when incidents occur. Without sufficient personnel, even well-intentioned staff may miss signs of mistreatment or fail to report violations.
Legal protections for residents and their families must also be expanded. Although the Nursing Home Reform Act, passed in 1987, established a federal framework for resident rights, enforcement remains inconsistent, and penalties are often too minimal to deter misconduct.[35]
Advocates have called for stronger whistleblower protections to shield staff who report abuse, broader access to civil litigation for victims and families, and harsher penalties for facilities that violate care standards.[36] These changes would empower individuals to seek justice and create stronger incentives for compliance.
In addition, improved Medicaid oversight is essential to ensure that public funds are used to support direct care rather than administrative overhead or profit margins. A final rule from CMS published last April requires that 80% of Medicaid payments go directly to care staff, helping to improve working conditions and reduce turnover.[37]
The rules also establish advisory committees composed of residents, caregivers and family members to enhance transparency and responsiveness in facility operations. By centering the voices of those most affected, these reforms aim to foster a culture of accountability and continuous improvement.
Ultimately, however, overcoming these and other barriers requires more than legal reform. It demands a cultural shift in how we value and protect older adults. Lawsuits alone will not fix a system that is structurally resistant to accountability. Education, advocacy and storytelling, like the "No Country for Old People" docuseries, play a critical role in reshaping public perception.
But until we confront the deeper attitudes that enable silence and indifference, even the most well-crafted legal arguments may fall short.
Veronica J. Finkelstein is an associate professor at Wilmington University School of Law. She previously served as an assistant U.S. attorney in the U.S. Attorney's Office for the Eastern District of Pennsylvania.
"Perspectives" is a regular feature written by guest authors on access to justice issues. To pitch article ideas, email expertanalysis@law360.com.
The opinions expressed are those of the author(s) and do not necessarily reflect the views of their employer, its clients, or Portfolio Media Inc., or any of its or their respective affiliates. This article is for general information purposes and is not intended to be and should not be taken as legal advice.
[1] See Mark Weiner, Van Duyn Owners Will Pay Millions to Settle Patient Neglect, Financial Fraud Claims; Onondaga Hill Nursing Home Will Be Overseen by Independent Monitors as Part of Settlement with New York State, The Post-Standard Online (Aug. 25, 2025), https://www.poststandard.com; Megan Guza, 2 Nursing Home Employees Charged with Neglect, Abuse, Pittsburgh Post-Gazette, Aug. 3, 2025, at C-4.
[2] See Richard W. Johnson & Judith Dey, Long-Term Services and Supports for Older Americans: Risks and Financing, 2022, ASPE Research Brief, HHS Ofc of the Asst Sec'y for Planning and Evaluation, Aug. 2022, available at https://aspe.hhs.gov/sites/default/files/documents/08b8b7825f7bc12d2c79261fd7641c88/ltss-risks-financing-2022.pdf.
[3] See Andrew Jay McClurg, Preying on the Graying: A Statutory Presumption to Prosecute Elder Financial Exploitation, 65 Hastings L.J. 1099, 1102 (2014); John A. Pearce II et al., Protecting Nursing Home Residents from Attacks on their Ability to Recover Damages, 61 Rutgers L. Rev. 705, 715 (2009); Jennifer N. Phan, The Graying of America: Protecting Nursing Home Residents by Allowing Regulatory and Criminal Statutes to Establish Standards of Care in Private Negligence Actions, 2002 Hous. J. Health L. & Pol'y 297, 301 (2002); David F. Bragg, Dealing with Nursing Home Neglect: The Need for Private Litigation, 39 S. Tex. L. Rev. 1, 15-16, 20-21 (1997).
[4] David Ray Papke, Good Intentions Are Not Enough: A Critique of Elderabuse Law, 31 Elder L.J. 279, 291-99 (2024).
[5] Elisia Gatmen Kupris, Protection of Our Elderly: A Multidisciplinary Collaborative Solution for Alaska, 30 Alaska L. Rev. 47, 51-52 (2013).
[6] Ari Ne'eman, Michael Stein, & David C. Grabowski, Nursing Home Residents Younger Than Age Sixty-Five Are Unique And Would Benefit From Targeted Policy Making, 34 Health Affairs 2120 (2015), https://www.healthaffairs.org/doi/epdf/10.1377/hlthaff.2022.00548.
[7] See Daniel L. Madow, Why Many Meritorious Elder Abuse Cases in California Are Not Litigated, 47 Univ. of San Francisco L. Rev. 619, 630 (2013).
[8] Id., note 82.
[9] See Papke, supra note 2, at 296-97.
[10] See Brenda K. Uekert, Susan Keilitz, & Deborah Saunders, Prosecuting Elder Abuse Cases: Basic Tools and Strategies 29 (2012).
[11] See Kerry Koehler, Comparative Shopping in Nursing Homes, 11 J. Health & Biomed. L. 439, 447-448 (2016).
[12] See Papke, supra note 2, at 296-97.
[13] See Priscilla Vargas Wrosch, What More Can Congress Do About the Elder Abuse Epidemic? A Proposal for National Movement, 23 Temp. Pol. & Civ. Rts. L. Rev. 1, 3 (2013).
[14] See Koehler, supra note 6, at 447-48.
[15] See David Ray Papke, The Stage Was Set for Disaster: For-Profit Nursing Homes, Federal Law, and COVID-19, 1 J. Elder Pol'y 199, 203 (2021).
[16] Angela Snellenberger Quin, Imposing Federal Criminal Liability on Nursing Homes: A Way of Deterring Inadequate Health Care and Improving the Quality of Care Delivered?, 43 St. Louis U. L.J. 653, 656, 686 (1999).
[17] Id.
[18] Katherine E. Barnett, Examining the Talevski Decision: Preserving Justice for Nursing Home Residents, 65 Ariz. L. Rev. 1047, 1059-60 (2023).
[19] Papke, supra note 2, at 296.
[20] See Joseph E. Casson & Julia McMillen, Protecting Nursing Home Companies: Limiting Liability Through Corporate Restructuring, 36 J. Health L. 577 (2004).
[21] See Jared Whitlock, Nursing Home Chain's Tangled Corporate Structure and Bankruptcy Threats Stymied Litigation, STAT (Aug. 5, 2022), https://www.statnews.com/2022/08/05/consulate.
[22] Id.
[23] See Linda Chen, Eradicating Elder Abuse in California Nursing Homes, 52 Santa Clara L. Rev. 213, 229 (2012).
[24] See Mary Helen McNeal and Maria Brown, Elder Restorative Justice, 21 Cardozo J. Conflict Resol. 91, 99-01 (2019).
[25] See Lori Stiegel, The Changing Role of the Courts in Elder-Abuse Cases, 24 Generations: J. Am. Soc'y on Aging 59, 60 (2000).
[26] Id.
[27] See Joseph W. Barber, The Kids Aren't All Right: The Failure of Child Abuse Statutes as a Model for Elder Abuse Statutes, 16 Elder L. J. 107, 123 (2008).
[28] See Catherine Hawes, Elder Abuse in Residential Long-Term Care Settings: What Is Known and What Information Is Needed? in Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America 446, 451 (Richard J. Bonnie & Robert B. Wallace eds., 2003).
[29] Stiegel, supra note 17.
[30] McNeal & Brown, supra note 16.
[31] U.S. Dep't of Health & Hum. Servs., Off. of Inspector Gen., Featured Topic: Nursing Homes, https://oig.hhs.gov/reports/featured/nursing-homes/ (last visited Sept. 2, 2025).
[32] See id.
[33] Understaffing in Nursing Homes-Consequences & Dangers, Nursing Home Abuse Ctr., https://www.nursinghomeabusecenter.com/nursing-home-neglect/understaffing/ (last visited Sept. 2, 2025).
[34] Ctrs. for Medicare & Medicaid Servs., Medicare and Medicaid Programs: Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting Final Rule (CMS-3442-F), https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid-0 (last visited Sept. 2, 2025).
[35] Nursing Home Reform Act (OBRA 1987 & 2023 Updates), Nursing Home Law Ctr., https://www.nursinghomelawcenter.org/news/nursing-home-reform-act-obra/ (last visited Sept. 2, 2025).
[36] See id.
[37] See http://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-Resources/Downloads/2012-medical-loss-ratio-report.pdf.