By Michael Shemtoub, trial attorney, Beverly Law. Updated November 2026.
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How Washington licenses each setting
The Department of Social and Health Services (DSHS) licenses all three, each under its own law.
- Assisted living facilities: chapter 18.20 RCW and chapter 388-78A WAC. RCW 18.20.020 defines them as places providing housing, basic services and general responsibility for residents’ safety, usually for seven or more.
- Nursing homes: chapter 18.51 RCW and chapter 388-97 WAC. Most are also Medicare and Medicaid certified, which adds federal rules.
- Adult family homes: chapter 70.128 RCW and chapter 388-76 WAC. They care for two to six adults, or up to eight with DSHS approval under RCW 70.128.010.
Level of care and nurse staffing
Under WAC 388-97-1080 and RCW 74.42.360, every nursing home must have a registered nurse (RN) as full-time director of nursing and an RN or licensed practical nurse (LPN) in charge on each shift. An RN must be on duty at least 16 hours a day. Homes with more than 60 licensed beds must have an RN on duty around the clock, unless the home is the only nursing home within a 40-minute drive or DSHS grants a limited exception. RCW 74.42.360 also requires at least 3.4 hours of direct care per resident per day.
The assisted living staffing rule, WAC 388-78A-2450, requires enough trained staff and at least one caregiver with current CPR and first-aid cards present at all times, but no nurse on duty. Nursing services are optional under WAC 388-78A-2310, and RCW 18.20.160 bars a facility from keeping someone who needs the frequent presence and evaluation of an RN.
Side-by-side comparison
| Assisted living facility | Nursing home | Adult family home | |
|---|---|---|---|
| License law | RCW 18.20; WAC 388-78A | RCW 18.51; WAC 388-97 | RCW 70.128; WAC 388-76 |
| Size | Usually 7 or more residents | 3 or more patients | 2 to 6 residents (8 with approval) |
| Nurse on duty | Not required | RN at least 16 hours a day; 24/7 in most homes over 60 beds | Not required |
| State inspection | At least every 18 months (24 with a clean record) | Standard survey within 15 months | At least every 18 months (24 with a clean record) |
| Medicare pays | No | Short-term skilled care only | No |
| Medicaid pays | COPES, if DSHS-contracted | Yes, if Medicaid-certified | COPES, if DSHS-contracted |
Who inspects, and how to read the reports
DSHS Residential Care Services inspects all three settings. Assisted living facilities and adult family homes must be inspected at least every 18 months, with a 15-month average, under RCW 18.20.110 and RCW 70.128.070. DSHS may wait up to 24 months after three clean inspections. Nursing homes get a federal standard survey within 15 months of the last one under 42 C.F.R. § 488.308.
To see a facility’s record, search the DSHS nursing home, assisted living or adult family home locator and open its reports page. It lists inspections, complaint investigations and enforcement letters by month.
Residents’ rights and payment
Assisted living and adult family home residents have the rights in chapter 70.129 RCW. Nursing home residents are covered mainly by federal law at 42 C.F.R. § 483.10, plus the parts of chapter 70.129 that RCW 18.51.009 applies to nursing homes.
Medicare generally pays for a short skilled nursing facility stay only after an inpatient hospital stay of at least three days in a row, and it does not pay for long-term custodial care in any setting. Our Medicare and nursing home FAQ has details. Washington Medicaid pays for nursing home care, and its COPES waiver can pay for care in an assisted living facility or adult family home that contracts with DSHS, for a person who meets nursing-facility level of care under WAC 388-106-0310.
When something goes wrong
The Abuse of Vulnerable Adults Act covers all three settings. RCW 74.34.200 lets a resident who was abused, neglected, abandoned or financially exploited in a facility sue for damages, and a plaintiff who proves the claim also recovers costs and reasonable attorney fees. Whether a claim succeeds depends on its facts and evidence. Under RCW 74.34.035, facility staff and operators must report suspected abuse or neglect to DSHS immediately, and to police when sexual or physical assault is suspected.
Many injury and abuse claims have a three-year deadline under RCW 4.16.080(2), but the deadline that applies depends on the claim. Health care negligence, such as a nursing error, falls under RCW 4.16.350: three years from the act or one year from discovery, whichever is later, with an eight-year outer limit in most cases. If a resident died, see our Washington wrongful death deadline FAQ.
What this means for your case
A resident with complex medical needs kept in assisted living may point to a problem under RCW 18.20.160.
- Note the facility’s exact name and license type from the DSHS locator, and save its reports.
- Ask for the care plan or negotiated service agreement, medication records and incident reports.
- Photograph injuries and keep hospital records.
- Report concerns to the DSHS Complaint Resolution Unit at 1-800-562-6078 or online. Call 911 in an emergency.
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Common questions
Can an assisted living facility keep my parent when their needs increase?
Not always. RCW 18.20.160 bars keeping a resident who needs frequent registered nurse evaluation, except for hospice care or a short illness expected to resolve within 14 days.
Does Medicare pay for assisted living in Washington?
No. Medicare does not pay for long-term custodial care. Medicaid’s COPES program may help if the facility contracts with DSHS.
Do memory care units have overnight staff?
Yes. WAC 388-78A-2450(3) requires a certified memory care facility or unit to keep awake caregiving staff 24 hours a day.
Does the vulnerable adult law apply to adult family homes?
Yes. RCW 74.34.020 defines a facility to include adult family homes, assisted living and nursing homes, so RCW 74.34.200 applies to all three.
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Related pages
Frequently asked questions · Washington injury lawyers · Seattle injury lawyer · Does Medicare pay for nursing home care? · How long does a nursing home lawsuit take? · Washington wrongful death deadline
Sources
- RCW 18.20 (assisted living facilities), chapter text
- RCW 18.20.020, assisted living facility definition
- RCW 18.20.110, assisted living inspection frequency
- RCW 18.20.160, residents needing frequent RN care
- WAC 388-78A, assisted living facility licensing rules
- WAC 388-78A-2450, assisted living staffing
- WAC 388-78A-2310, intermittent nursing services in assisted living
- RCW 18.51 (nursing homes), chapter text
- RCW 18.51.009, resident rights provisions applied to nursing homes
- WAC 388-97, nursing home licensing rules
- WAC 388-97-1080, nursing home nursing services and RN coverage
- RCW 74.42.360, nursing home minimum direct care staffing
- RCW 70.128 (adult family homes), chapter text
- RCW 70.128.010, adult family home definition
- RCW 70.128.070, adult family home inspection frequency
- WAC 388-76, adult family home licensing rules
- RCW 70.129, long-term care resident rights
- RCW 74.34.200, Abuse of Vulnerable Adults Act civil cause of action
- RCW 74.34.035, mandatory reporting of vulnerable adult abuse
- RCW 74.34.020, definitions including facility and mandated reporter
- RCW 4.16.080, three-year statute of limitations
- RCW 4.16.350, health care negligence statute of limitations
- WAC 388-106-0310, COPES eligibility
- 42 C.F.R. § 483.10, nursing facility resident rights (eCFR)
- 42 C.F.R. § 488.308, nursing facility survey frequency (eCFR)
- DSHS Nursing Home Locator, inspection and enforcement reports
- DSHS Assisted Living Facility Locator, inspection and enforcement reports
- DSHS Adult Family Home Locator, inspection and enforcement reports
- DSHS Residential Care Services
- DSHS, Long-Term Care Residential Options
- DSHS, Report Concerns Involving Vulnerable Adults
- Medicare.gov, Skilled nursing facility care coverage
- Medicare.gov, Long-term care coverage
Important: This page is general information, not legal or medical advice, and reading it does not create an attorney-client relationship. Every case is different; talk to a lawyer about yours. Last reviewed: November 7, 2026.