Warning Signs: How Caregivers Can Spot Elder Abuse and Neglect

Be vigilant for signs of mistreatment in nursing homes — it’s more common than many realize

Paul Wynn,

AARP

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Published October 08, 2025

Molly Snee

The doors of a Virginia-based nursing home will soon close after federal regulators took the rare step of imposing extreme enforcement actions. Health inspectors documented repeated cases of neglect and lapses in care at Princess Anne Health & Rehabilitation Center in Virginia Beach. In one case, a family member discovered their loved one bleeding heavily from a fall that left them with a severe injury. The investigation also found patients suffered from advanced pressure ulcers, or bedsores, and residents wandered the streets and injured themselves — clear signs of repeated neglect.

While shocking, it’s not rare. Bianca Graham-Bruce, a care manager in Charlotte, North Carolina, played a pivotal role in protecting her client — a woman with mild dementia — from physical abuse in a separate Northern Virginia rehab facility. One day when they were together, Graham-Bruce’s client fidgeted and could barely speak, but after encouraging her to open up, the woman finally shared that a male staff member had restrained her during a visit. Graham-Bruce immediately notified the client’s long-distance daughter and collaborated with the facility and Adult Protective Services to conduct an investigation. The agency ultimately closed the case after relocating the client. Graham-Bruce encourages families to take protective action. “Nursing home residents may not always be able to speak up, but they can always be protected, if someone is willing to listen and act,” she says.

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In 2023, nursing homes received 94,499 health citations, according to the Centers for Medicare & Medicaid Services, with 8.1 percent of the citations (7,654) related to abuse, neglect or exploitation of residents. Experts believe abuse frequently goes unnoticed and underreported. A 2020 study surveyed 897 older adults during the COVID-19 stay-at-home orders to estimate elder abuse prevalence. Researchers at Yale University found that 21 percent reported abuse, an 84 percent increase from pre-pandemic levels.

Types of abuse and neglect

Elder abuse and neglect are frequently overlooked but can cause devastating harm to residents living in nursing homes. Susan Carson, a registered nurse with more than two decades of forensics experience, emphasizes that elder abuse doesn’t always leave bruises you can see. “Sometimes the wounds are emotional, financial or hidden so that it’s hard to detect.” She says that abuse and neglect can take many forms, including:

Physical abuse: Inflicting pain or injury on an older adult.
Confinement: Restraining or isolating an older adult for reasons other than medical necessity.
Emotional or psychological abuse: Verbal assaults, threats, harassment or intimidation.
Financial exploitation: Misusing or withholding an older adult’s money, property or other resources.
Passive neglect: Failing to provide basic needs such as food, medications or medical care.
Sexual abuse: Any sexual contact — touching, fondling, intercourse or other activity — with an older adult who cannot understand, cannot consent, is threatened or is physically forced.
Theft: Illegally taking someone’s personal property, such as jewelry, cash, electronics or other valuable possessions without the victim’s knowledge or consent.

“Detecting abuse is complicated by the fact that many older adults are hesitant to speak out due to fear, dependency or cognitive impairment,” says Carson, who has assisted more than 500 victims through evidence collection, injury documentation and courtroom testimony.

Spotting the signs

Carson stresses that elder abuse can be subtle and multifaceted.

Behavioral changes. Fear, withdrawal or reluctance to speak in front of staff members, which may signal intimidation or coercion.
Poor hygiene and unmet basic needs. Malnutrition, dehydration, dirty clothing or bedding, or untreated medical conditions.
Neglectful supervision. Residents left unattended outdoors in heat or cold, allowed to wander off the property, or not assisted with eating or toileting.'
Humiliation or psychological abuse. Staff members ridiculing or taunting residents, filming them without consent, or posting images online.
Sexual assault or inappropriate touching. Especially of residents who are cognitively impaired, have few visitors or are isolated at night.
Severe or unexplained injuries. Repeated unexplained falls, broken bones, especially in arms from a twisting motion, bruising in unusual places, burns or untreated pressure sores (Stage-4 bedsores are a major red flag).
Theft. Missing jewelry, cash or personal belongings, sudden changes in bank accounts or spending patterns.

Adopt a prevention mindset

Families can play a powerful role in safeguarding loved ones in long-term care. Donna Rein, a former nursing home administrator and now consultant with LionHeart Eldercare in Falls Church, Virginia, recommends being a visible presence. “Families can do this by not only spending time at the facility with their loved one, but learning staff names, building relationships with nurses, activity directors, housekeepers and front-desk personnel,” she says.

Former U.S. attorney Rick Mountcastle recommends that families shouldn’t just visit nursing homes at predictable times. He recommends showing up on weekends and during the night shift because many facilities are understaffed, and it’s during these more unpredictable times that problems with care are most visible. “Making unannounced visits at off hours to see the ‘real’ conditions can help identify care issues,” says Mountcastle, a producer of a new documentary, No Country for Old People, which raises awareness of the failures of the long-term care system.

Graham-Bruce highlights that one of the most critical steps in protecting family members from abuse is ensuring that the facility itself takes the situation seriously. This means having administrators, such as the executive director and director of nursing, readily available and responsive when concerns arise. “Establish a clear communication plan that includes the administrator’s direct contact information, and bring any concerns or issues straight to leadership,” she adds.

For families who care from a distance, hiring a care manager can provide trusted eyes and ears on the ground. “Expect some imperfections at nursing homes, but watch for patterns,” explains Rein. “Isolated mistakes are not out of the ordinary, but repeated issues can point to deeper, systemic problems that need to be checked out.”

How to report abuse

Retired career prosecutor Paul Greenwood has spent more than two decades putting elder abusers behind bars. Now, as an ambassador with AARP’s Fraud Watch Network, he’s urging families to take an active role in protecting loved ones in long-term care settings.

“Don’t hesitate if you see something wrong, make a report,” Greenwood says. “Even if you’re not sure it’s a crime, a written complaint is far harder for authorities to ignore than a phone call.” Greenwood’s advice for families blends vigilance with the following practical steps that can preserve evidence, trigger investigations and ultimately keep vulnerable family members safer.

Check first. Before choosing a facility, look up its state inspection reports, drop in unannounced at different times, and note staff–resident interactions.
Consider cameras. Ask about state laws and facility rules on in-room cameras. If permitted, they can provide valuable documentation.
Act fast on serious harm. For suspected assault, severe neglect or theft, call the police immediately — before notifying the facility — to preserve evidence.
Put complaints in writing. Send a brief, factual letter to police or regulators rather than only making a phone call; written reports are harder to ignore.
Notify regulators. After contacting police, report to your state licensing agency and the local long-term care ombudsman, which should be provided by the nursing home. Find your state’s ombudsman program — available here.
Document everything. Keep dates, times, photos and names of anyone involved.
Know when to escalate. Minor concerns (slow response times, food quality) can go to the administrator first. Major concerns of abuse and neglect should go straight to law enforcement.
Seek legal expertise. If civil action is necessary, look for an attorney experienced in elder-abuse or nursing-home litigation. Check with local bar associations for referral lists.
Plan a backup home. Be ready to move your loved one if conditions are unsafe, even if it takes time to find a new placement.

“Don’t wait to act if something seems wrong, take decisive steps to make a difference in protecting your loved one,” says Greenwood. “Families who stay vigilant can prevent harm and make sure their loved ones receive the care they deserve.”

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Paul Wynn, a veteran health care writer, has spent over a decade immersed in the caregiving community, both as a family caregiver and as a journalist covering caregiving issues for national publications.