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A recent piece from ElderLawAnswers laid out something families planning for a facility move often don't hear until it's too late: moving into a nursing home doesn't mean surrendering the right to make decisions about your own life. This piece builds on that one, with an eye toward what a family in Ohio, Missouri, or Alabama can actually do with that information the day it matters.
What Federal Law Actually Protects
The legal floor. Every nursing home certified to accept Medicare or Medicaid, regardless of how any individual resident actually pays, has to follow the Nursing Home Reform Law of 1987, which requires the facility to help each resident "attain or maintain the highest practicable physical, mental, and psychosocial well-being." The implementing regulation, 42 CFR § 483.10, spells out the resident-rights piece of that promise in detail. Assisted living is governed more loosely, mostly by state law, but a facility that accepts Medicaid home- and community-based services funding has to follow the federal HCBS settings rule, built around the same core idea: dignity, autonomy, and an environment that feels like a home rather than an institution.
Why do residents let it slide? The rights exist on paper more reliably than they get used in practice, and the reasons are consistent: residents often don't know the rights are there, they defer to staff who run "a large, established operation" and must know best, they're afraid of confrontation or retaliation from the same people caring for them every day, and isolation from the outside world leaves many with no one to compare notes with. Left unchallenged, small accommodations denied become a pattern, and the pattern becomes the resident's new normal. This is the same dynamic that shows up in the isolation-first sequence I've written about elsewhere on this blog in the context of caregiver exploitation: a single point of control, uncontested, tends to expand.
The Care Plan as Lever
The care plan is the actual lever, not a formality. Federal regulation puts the resident at the "locus of control" of their own care plan — not a box to sign off on, but something the resident and family should actively shape. A baseline plan is required within 48 hours of admission, and a full, person-centered plan within seven days of the comprehensive assessment, built by a team that includes the resident's physician, nursing staff, dietary staff, and anyone else the resident asks to be there.
A good plan covers more than diagnoses and medication times. It should address nutrition and religious or cultural food preferences, when the resident is actually alert enough to enjoy a visit, mobility and communication supports, personal goals including any interest in a less restrictive setting, and the small things, such as a favorite chair, a regular hobby, that keep someone feeling like a person rather than a bed number. Ask for a real meeting, not fifteen rushed minutes. Bring a written list. Ask for a copy of the plan itself, and revisit it. Needs and cognition both change, and a plan frozen at intake stops describing the person it's supposed to serve.
Visitation
Visitation is broader than most facilities act like it is. Some have arbitrary and burdensome rules. A legal representative, ombudsman, protection-and-advocacy representative, physician, and family members must get immediate access. Everyone else needs the resident's consent, not the facility's permission. Capping visitor counts, enforcing rigid hours, or requiring advance scheduling are restrictions facilities apply far more often than the law actually allows. Legitimate limits are narrow: the resident's own request, something specific in the care plan, or a documented clinical or safety concern, and even those shouldn't be accepted at face value.
Medication Consent
Medication consent is where the stakes get highest. Before starting or increasing a medication, a resident has to be told its purpose, risks, benefits, and alternatives, and may decline it. CMS reinforced this right in its 2025 surveyor guidance specifically because facilities kept skipping the documentation. This matters most with antipsychotics, which have a long, well-documented history of being used to sedate a difficult resident rather than treat a diagnosed condition. Asking the question up front — what is this for, what happens if we say no — heads off the much harder fight of arguing after the fact that a drug was never medically necessary.
Voting
Residents keep the right to vote, including the right to get help marking a ballot from a person of their own choosing, not the facility's. CMS reaffirmed this directly in a September 2024 memo reminding facilities that residents must be free to vote "without interference, coercion, discrimination, or reprisal," and issued further guidance in July 2026 reinforcing the same point heading into this year's elections. With an election on the horizon, check the state's specific rules on registration and mail voting, since some states send a ballot automatically and others require a request, and a facility or family member can legitimately help with registration, the ballot request, or transportation to a polling place, but no one may vote on a resident's behalf or steer their choice.
Enforcing Your Rights
When a facility won't budge, raise it with staff first, then with the facility's long-term care ombudsman. If that does not work, file a complaint with the state survey agency, and consider a resident or family council if the facility has one. Ohio's ombudsman program can be reached through the Ohio Department of Aging at 1-800-282-1206; Missouri's through the Department of Health and Senior Services at 1-800-309-3282; and Alabama's through the Alabama Department of Senior Services at 1-877-425-2243. An elder law attorney is the next step when a pattern has formed rather than a single bad afternoon. None of these routes move quickly, and persistence is often what separates a resolved complaint from one that quietly goes nowhere.
The federal “Bill of Rights” in 42 C.F.R. § 483.10 is still real as regulation: dignity, self-determination, participation in care planning, grievances, access to records, and related duties. Facilities must protect those rights to stay certified. Unfortunately, the federal law does not typically confer a right to seek recourse for deprivation of these rights. The case discussed in the hyperlinked article was from 2015, and is still generally true. What has changed is that in 2023, the Supreme Court, in Health & Hospital Corp. of Marion County v. Talevski, 599 U.S. 166 (2023), held that specified FNHRA provisions do create individual rights enforceable under 42 U.S.C. § 1983. The rights at issue were freedom from unnecessary chemical restraints and the transfer/discharge protections. The Court rejected the argument that Spending Clause statutes like FNHRA can never support a § 1983 suit. Seven justices joined the holding.
The update still has limits, and those limits are why the old post was only half-wrong rather than wholly wrong:
- § 1983 Needs a State Actor: Talevski involved a county-owned home. Most nursing homes are private. A private facility is not automatically a § 1983 defendant. Families still usually sue in state court for negligence, wrongful death, or a state residents-rights statute.
- Not Every Sentence in § 483.10 is a § 1983 Right: Talevski covered particular, rights-sounding FNHRA provisions. A court can still treat other participation requirements as funding conditions rather than individual rights.
- No Specific Right: FNHRA still has no stand-alone private right of action in its own text. The vehicle is § 1983 (against state actors) plus CMS survey, citations, civil money penalties, and the ombudsman. The 2015 observation that the statute was written as a Medicare/Medicaid condition of participation remains descriptively true. What changed is the Supreme Court’s conclusion that some of those conditions also confer enforceable rights.
The statutes that actually create a lawsuit are usually state statutes. Ohio. Rev. Code § 3721.13 lists residents’ rights, and § 3721.17 gives a resident (or specified family members, in order) an express cause of action against “any person or home” that violates those rights, with injunctive relief and compensatory damages if negligence proximately caused injury, death, or loss. That is a private right of action.
Similalrly, in Missouri, Rev. Stat. § 198.088 requires facilities to inform residents of rights and to have grievance procedures. Section 198.093 lets a resident or estate complain to the attorney general and, if the AG does not sue within 60 days, bring a civil action for actual damages, limited punitive damages, attorney fees, and equitable relief, while also preserving ordinary tort claims. That is a private remedy with a procedural on-ramp, not “no redress.”
Just a final note. Assisted living is mostly outside FNHRA. FNHRA applies to Medicare/Medicaid nursing facilities. Assisted living rights and remedies are almost entirely state law, contract, and licensing.
