United States Government Accountability Office

GAO Report to Congressional Requesters

LONG-TERM CARE 

FACILITIES 

Information on 

Residents Who Are 

Registered Sex 

Offenders or Are 

Paroled for Other 

Crimes 

March 2006 

 

GAO-06-326 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

March 2006

LONG-TERM CARE FACILITIES 

Information on Residents Who Are 

Registered Sex Offenders or Are Paroled 

for Other Crimes 

Highlights of GAO-06-326, a report to 

congressional requesters 

Approximately 23,000 nursing 

homes and intermediate care 

facilities for people with mental

retardation (ICF-MR) receive 

federal Medicare and Medicaid

funding. Media reports have cited

examples of convicted sex 

offenders residing in long-term care

facilities and, in some cases, 

allegedly abusing other residents.

Given concerns about resident

safety, GAO was asked to assess 

(1) the prevalence of sex offenders 

and others on parole for non-sex

offenses living in long-term care

facilities and the extent of any

abuse they may have caused, 

(2) the legal requirements for 

notifying facilities and others when

offenders are residents, and (3) the 

extent to which facilities have

different supervision and 

separation requirements for 

offenders. GAO analyzed a national

database for sex offenders and

analyzed state databases in a

sample of eight states for sex

offenders and parolees. 

What GAO Recommends

GAO recommends that the Federal 

Bureau of Investigation (FBI) 

assess the completeness of the 

National Sex Offender Registry

(NSOR), including state submission

rates, and evaluate options to 

increase its comprehensiveness. 

The Department of Justice (DOJ)

commented that these

recommendations are unnecessary 

because of efforts already in place. 

GAO recognizes these efforts but 

maintains that the 

recommendations remain valid. 

By analyzing the FBI’s NSOR, which is a compilation of sex offender 

registries submitted by all states, GAO identified about 700 registered sex 

offenders living in nursing homes or ICFs-MR during 2005. Most identified 

sex offenders were male, under age 65, and living in nursing homes, and 

represented 0.05 percent of the 1.5 million residents of nursing homes and 

ICFs-MR. About 3 percent of nursing homes and 0.7 percent of ICFs-MR 

housed at least 1 identified sex offender during 2005. However, these 

estimates are understated due to data limitations. For example, because of a 

lack of resources or an inability to comply with certain FBI reporting 

requirements, states have had varying degrees of difficulty submitting their 

full state registries to the NSOR. While the FBI does not track NSOR 

submission rates, GAO compared sex offender registry data from seven of 

the eight states reviewed to NSOR data and found that the NSOR data 

included about 57 percent of sex offenders registered in these states, with 

submission rates ranging from 1 percent to 83 percent. Because a national

data source on parolees that included address information was not available, 

GAO also obtained parolee databases from the eight reviewed states and 

identified 204 offenders on parole for non-sex offenses living in long-term 

care facilities. GAO could not determine the overall risk that registered sex 

offenders and parolees pose to other residents in long-term care facilities

because offender status is not tracked with abuse reporting. Facility

administrators expressed greater concern over the risk posed by cognitively 

impaired or mentally ill residents. 

Federal law requires state law enforcement agencies to release relevant 

information about registered sex offenders when necessary to protect the 

public, but GAO did not identify a similar federal law for the parolee 

population. States have broad discretion in how to implement the 

requirement for registered sex offender notification. Therefore, the extent to 

which states’ community notification laws apply to all registered sex 

offenders or explicitly include long-term care facilities varies. For example, 

four of the eight states GAO reviewed—California, Illinois, Minnesota, and 

Oklahoma—had laws that specified long-term care facilities as entities to be 

notified for at least some registered sex offenders who entered them. 

However, some facility administrators GAO contacted were uncertain as to 

whether they could share information with staff and others about residents 

who were known offenders in light of the Privacy Rule issued under the 

Health Insurance Portability and Accountability Act of 1996 (HIPAA). 

Long-term care facilities GAO contacted do not routinely impose different 

supervision or separation requirements on residents who are offenders 

based solely on their prior convictions. Instead, these facilities base such 

decisions on the demonstrated behaviors of residents. Even if long-term care 

facilities wanted to impose different supervision and separation 

requirements on offenders, their ability to do so is limited because they are 

not always aware of residents’ prior convictions. 

www.gao.gov/cgi-bin/getrpt?GAO-06-326.

To view the full product, including the scope 

and methodology, click on the link above. 

For more information, contact Kathryn G. 

Allen at (202) 512-7118 or allenk@gao.gov. 
Contents 

Letter 1

Results in Brief 3 

Background 6

Identification of Offenders Living in Long-Term Care Facilities and 

Assessment of the Risk They Pose Limited by Data 

Shortcomings 11

States Required to Notify Community about Registered Sex 

Offenders, but Extent of Notification Varies 18 

Supervision and Separation of Long-Term Care Facility Residents 

Largely Based on Behavior, Not Prior Convictions 25 

Conclusions 26

Recommendations for Executive Action 27 

Agency and State Comments and Our Evaluation 27 

Appendix I Scope and Methodology 31 

Appendix II Registered Sex Offenders Living in Nursing Homes 

and ICFs-MR 34 

Appendix III Comments from the Department of Justice 36 

Appendix IV Comments from the Department of Health and 

Human Services 41 

Appendix V GAO Contact and Staff Acknowledgments 43 

Tables 

Table 1: Estimated Submission Rates to NSOR, by States Reviewed, 

2005 14 

Table 2: Parolees Identified as Living in Long-term Care Facilities 

in States Reviewed, 2005 16 

Table 3: Validity of Offender Address Data by Data Source 32 

Page i GAO-06-326 Offenders in Long-Term Care Facilities
Table 4: Registered Sex Offenders Identified as Living in Nursing 

Homes and ICFs-MR, by State, 2005 34 

Abbreviations 

CMS Centers for Medicare & Medicaid Services 

FBI Federal Bureau of Investigation 

HHS Department of Health and Human Services 

HHS-OCR Department of Health and Human Services Office for 

 Civil Rights 

HIPAA Health Insurance Portability and Accountability Act of 1996 

ICF-MR intermediate care facility for people with mental 

 retardation 

NNHS National Nursing Homes Survey 

NORS National Ombudsman Reporting System 

NSOR National Sex Offender Registry 

OSCAR Online Survey, Certification and Reporting system 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. It may be reproduced and distributed in its entirety without further 

permission from GAO. However, because this work may contain copyrighted images or 

other material, permission from the copyright holder may be necessary if you wish to 

reproduce this material separately. 

Page ii GAO-06-326 Offenders in Long-Term Care Facilities
United States Government Accountability Office

Washington, DC 20548 

March 31, 2006 

The Honorable Charles E. Grassley 

Chairman 

Committee on Finance 

United States Senate 

The Honorable Henry A. Waxman 

Ranking Minority Member 

Committee on Government Reform 

House of Representatives 

The Honorable Betty McCollum 

House of Representatives 

Approximately 16,000 nursing homes and 6,600 intermediate care facilities 

for people with mental retardation (ICF-MR) participate in Medicare, 

Medicaid, or both, and receive federal funding to care for their residents. 

Federal Medicare and Medicaid funds accounted for a significant portion 

of total funding to these nursing homes and ICFs-MR—approximately 

$43 billion of a total of over $110 billion in 2003, with about $37 billion 

spent in nursing homes and $6 billion in ICFs-MR.1

 Because of the large

amount of federal funding these long-term care facilities receive, there is a 

strong interest in ensuring the safety and well-being of their vulnerable 

residents. 

Concerns about the quality of care provided to residents of long-term care 

facilities are long-standing. Since 1998, a number of congressional hearings 

have focused on ensuring the quality of care and protecting the safety and 

rights of nursing home residents. Recently, news outlets and others have 

reported accounts of convicted sex offenders residing in nursing homes 

and, in some cases, allegedly abusing other residents. Often, nursing home 

staff and residents’ families were not informed when convicted sex 

offenders were residents. The admission to long-term care facilities of 

individuals on parole for non-sex offenses2 raises similar concerns about 

 1

For this report, we refer to nursing homes and ICFs-MR together as long-term care 

facilities.

2

For this report, we refer to registered sex offenders and other offenders on parole for nonsex offenses as offenders. 

Page 1 GAO-06-326 Offenders in Long-Term Care Facilities
the potential for abuse. Because of your concerns about resident safety, 

we are providing information on (1) the prevalence of offenders living in 

nursing homes and ICFs-MR and the extent of abuse caused by such 

offenders in these long-term care facilities; (2) whether federal and state 

laws provide for notification of staff, residents’ families, and residents 

when such offenders live in these long-term care facilities; and (3) the 

extent to which these offenders are subject to supervision or separation 

requirements that differ from those for other residents. 

To determine the prevalence of registered sex offenders residing in these 

long-term care facilities nationwide, we obtained the Federal Bureau of 

Investigation’s (FBI) National Sex Offender Registry (NSOR), a national 

database utilized by law enforcement that compiles information about 

registered sex offenders submitted by all 50 states and the District of 

Columbia, as of January 3, 2005. We used the NSOR to identify the home 

addresses of registered sex offenders and matched them with the 

addresses of nursing homes and ICFs-MR included in the Centers for 

Medicare & Medicaid Services’ (CMS) Online Survey, Certification and 

Reporting system (OSCAR) database, which compiles the results of state 

nursing home surveys. To assess the completeness of the NSOR data, we 

requested complete sex offender registries from eight states—California, 

Florida, Illinois, Minnesota, Ohio, Oklahoma, New Jersey, and Utah—

which we selected on the basis of a number of criteria, including variation

in geographic location and in the number of registered sex offenders 

identified as living in these states’ long-term care facilities based on our 

preliminary analyses. Seven of the eight states provided their sex offender

registries, and we compared the total number of sex offenders on each of

the state registries with the total number for each state identified through 

the NSOR.3

 In the course of comparing the results of the NSOR and state 

sex offender registries analyses, we became aware that the NSOR did not 

include the full sex offender registries of these states. Since no national 

database exists for parolees that includes address information, we also 

obtained parolee databases from each of these eight states. We matched 

parolee addresses with addresses for nursing homes and ICFs-MR from 

OSCAR for the eight states; however, because of the limited number of 

states reviewed, we could not generalize these results as representative of 

all states. We obtained state registries and parolee databases from January 

through September 2005. 

 3

California state officials did not provide us with the state’s sex offender registry in view of

their concerns with state privacy laws. 

Page 2 GAO-06-326 Offenders in Long-Term Care Facilities
To gather information about the administration and content of state sex 

offender registries, including their submission of records to the NSOR, we 

interviewed state registry administrators from all eight states and 

submitted a questionnaire via e-mail to all other states, receiving 

responses from an additional 20 states. To assess the reliability of FBI and 

state data, we discussed data quality control procedures, reviewed 

relevant documentation with officials, and conducted electronic data 

testing. We determined that while the NSOR does not include all registered 

or convicted sex offenders, its records are regularly audited and are 

sufficiently reliable for the purposes of this report. The lack of 

comprehensiveness of the data was evaluated and taken into account in

our discussion of the results. We determined that the OSCAR database and 

state parolee databases were sufficiently reliable for our purposes. 

To obtain information about resident abuse perpetrated by sex offenders

and parolees residing in long-term care facilities, we reviewed existing 

research and GAO reports and interviewed officials of industry 

associations and long-term care ombudsmen. Within the eight states we 

reviewed, we also interviewed state officials responsible for nursing home 

and ICF-MR licensing, as well as administrators at 29 of 32 judgmentally 

selected long-term care facilities—-4 from each state. We also relied on 

these interviews, interviews with federal officials, and a review of federal 

and state laws to determine whether federal and state laws provide for 

notification of facility staff, residents, and residents’ families when 

offenders live in these long-term care facilities and the extent to which 

offenders are supervised and separated from other residents. In the eight 

states we reviewed, we also examined states’ public sex offender Web site

registries to determine what information on registered sex offenders is 

available to the public. We conducted our work from September 2004 

through February 2006 in accordance with generally accepted government 

auditing standards. (For additional information on our scope and 

methodology, see app. I.) 

Using the FBI’s NSOR, we identified about 700 registered sex offenders 

living in long-term care facilities during 2005, representing 0.05 percent of 

the 1.5 million residents of these facilities. About 3 percent of nursing 

homes and 0.7 percent of ICFs-MR housed a registered sex offender during 

2005. Almost 90 percent of registered sex offenders we identified lived in 

nursing homes and were considerably younger than the general nursing 

home population, with 57 percent under age 65 compared to about 

10 percent of all nursing home residents. However, our count is 

understated because of limitations in data availability. For example, while 

Results in Brief 

Page 3 GAO-06-326 Offenders in Long-Term Care Facilities
the NSOR is a national database that compiles information about 

registered sex offenders submitted by all 50 states and the District of 

Columbia, it does not include convicted sex offenders who are not on state 

registries, including those who were convicted or released from prison 

before registration requirements went into effect and those who are 

required by law to register but do not comply. While noncompliance is 

difficult to track, four of the eight states we reviewed estimated 

noncompliance rates that ranged from 4.5 percent to 25 percent of all sex 

offenders required to register. In addition, because of a lack of resources 

or an inability to comply with certain FBI reporting requirements, states 

have had varying degrees of difficulty submitting their full state registries 

to the NSOR. While the FBI does not track NSOR submission rates, our 

analyses of the registries obtained from seven of the eight states we 

reviewed indicated NSOR submission rates averaging about 57 percent, 

ranging from 1 percent to 83 percent, while the 20 other states that 

responded to our e-mail questionnaire reported NSOR submission rates 

ranging from 46 percent to 100 percent. Because there is no national data

source on parolees that includes address information, we obtained parolee 

databases from all eight states we reviewed and identified 204 offenders 

on parole for non-sex offenses living in long-term care facilities. We could 

not estimate the overall risk these registered sex offenders and parolees 

pose to other residents in long-term care facilities because data are not 

available in the reviewed states on abuse perpetrated specifically by 

residents who have prior convictions. Facility administrators we 

interviewed more frequently expressed concern over the potential for 

abuse by residents with cognitive impairments or mental illness than those 

with prior convictions. 

Federal law requires state law enforcement agencies to release relevant 

information about registered sex offenders when necessary to protect the 

public, but we did not identify a similar federal law for the parolee 

population. States have broad discretion on how to implement this 

requirement for registered sex offenders and often do so through a 

process known as community notification. Consequently, the extent to 

which states’ community notification laws apply to all registered sex 

offenders or explicitly include long-term care facilities varies, and this 

variation was evident in the eight states we reviewed. For example, while 

two states we reviewed apply uniform community notification 

requirements to all registered sex offenders, the six remaining states vary 

these notification requirements depending on the crime committed by the 

registered sex offender or risk to re-offend. Similarly, only half of the 

states we reviewed specify that long-term care facilities be notified when 

at least some registered sex offenders are residents. Long-term care 

Page 4 GAO-06-326 Offenders in Long-Term Care Facilities
facilities in the remaining four states, or in states where community 

notification of these facilities is not required for all registered sex 

offenders, may not be aware of residents who are offenders or must rely 

on other methods, such as publicly available state Web site registries, to 

identify such individuals. While we identified no federal law that requires 

community notification for parolees when they enter long-term care 

facilities, three of the eight states we reviewed require community 

notification for all or a subset of parolees. When long-term care facility 

residents are known offenders, opinions differ among state and long-term 

care officials we interviewed as to whether sharing information with other 

residents and staff about such offenders’ prior convictions violates the 

Privacy Rule issued under the Health Insurance Portability and 

Accountability Act of 1996 (HIPAA). For example, while some state agency 

officials indicated that the HIPAA Privacy Rule only applied to individuals’ 

health information and not their prior convictions, some long-term care 

facility officials thought the HIPAA Privacy Rule prohibited the sharing of 

any such information in most cases. Despite concerns that they may 

violate the HIPAA Privacy Rule by disclosing information about the prior 

convictions of certain residents, some long-term care facility officials said 

that they would still notify staff if they became aware of such residents. 

We brought the issue of long-term care facilities’ uncertainty regarding the 

applicability of the HIPAA Privacy Rule to the attention of the Department 

of Health and Human Services (HHS) in the event that this issue gains 

more prominence in the future. 

Having a prior conviction typically is not sufficient to subject offenders to 

supervision or separation requirements that differ from those for other 

residents, according to long-term care facility officials we interviewed. 

Instead, these facilities generally base supervision and separation 

requirements for residents on behavioral issues as they arise. Several longterm care ombudsmen, industry association officials, and facility officials 

in the states we reviewed indicated that the residents they are most 

concerned about in terms of behavioral problems are those with mental 

illness, particularly dementia, for which behaviors are apt to change as the 

disease progresses. Officials at only 2 of the 29 long-term care facilities we 

contacted said they have a specific policy to separate offenders from other 

residents based solely on their prior convictions. Even if long-term care 

facility officials wanted to impose different separation and supervision 

requirements on offenders, their ability to do so may be limited. Not only 

are long-term care facilities not always notified when individuals with 

prior convictions enter them, the assessment tools they use to determine 

the health care needs of residents typically do not gather information 

about prior convictions. In addition, in the event that a facility obtained 

Page 5 GAO-06-326 Offenders in Long-Term Care Facilities
such information, federal and state laws that we reviewed generally do not

provide for specific supervision or separation requirements for facility 

residents with prior convictions. 

While it was not part of our original objectives to fully evaluate the NSOR, 

in the course of our work using the NSOR to identify registered sex 

offenders residing in long-term care facilities, we became aware that the 

database was incomplete for the seven states we reviewed for this 

purpose. Therefore, to ensure that NSOR fulfills its potential as a national

database on registered sex offenders, we recommend that the Attorney 

General direct the FBI to assess the completeness of the NSOR, including 

state submission rates, and to evaluate options for making it a more 

comprehensive national database of registered sex offenders.

In commenting on a draft of this report, the Department of Justice (DOJ) 

said it believes the recommendations are unnecessary because the FBI 

already performs assessments of the NSOR and explores options for 

improvement. While we acknowledge the states’ and FBI’s efforts and 

progress to date, we maintain that the intent of the recommendations 

remains valid based on our analysis of a sample of states that indicates 

some states are not submitting a significant percentage of registered sex 

offender records to the NSOR. However, to be more specific regarding the 

need to assess the completeness of NSOR, we revised the 

recommendations to clarify that the FBI should assess state submission 

rates. HHS commented that the report will help to resolve much of the 

uncertainty about the application of the HIPAA Privacy Rule to the 

disclosure of conviction information by a facility, including clarifying that 

information could be used for activities necessary for the safe operation of

the facility or disclosures that are required by state laws. 

Nursing homes provide a residential setting and a range of health care 

services for individuals who can no longer care for themselves because of

physical or mental limitations. According to the most recent National 

Nursing Homes Survey (NNHS), approximately 90 percent of nursing 

home residents were age 65 and older and more than two-thirds were 

female.4

 ICFs-MR are intended to provide a residential setting for 

treatment, rehabilitation, and supervision of people who have mental 

Background 

 4

The NNHS is conducted by the Centers for Disease Control and Prevention’s National 

Center for Health Statistics. 

Page 6 GAO-06-326 Offenders in Long-Term Care Facilities
retardation or other disabilities, such as seizure disorders or behavior 

problems. In 2005, approximately 85 percent of ICF-MR residents were 

from 22 to 65; only 7 percent of the total resident population was over 

65 years of age. In addition, unlike the nursing home population, the 

majority of ICF-MR residents were male. 

Approximately 1.5 million individuals lived in Medicaid- and Medicarecertified nursing homes and ICFs-MR in 2005.5

 Federal Medicaid and

Medicare funds accounted for approximately 33 percent of total spending

on nursing homes, and the remaining funds were from a combination of 

state, local, and private sources in 2003. In the same year, ICFs-MR, which 

are funded almost exclusively by Medicaid, received about 58 percent of 

their total funding from federal Medicaid funds and the remainder from 

state Medicaid dollars. Medicaid, a joint federal-state program that 

finances health care coverage for certain categories of low-income 

individuals, is the primary payment source for long-term care services for 

older people with low incomes and limited assets. Medicaid pays for an 

array of long-term care services, including services to assist people with 

activities of daily living like eating, dressing, bathing, and using the 

bathroom. In contrast, Medicare, which covers a variety of health care 

services and items for individuals who are 65 or older, have end-stage 

renal disease, or are disabled, does not pay for most long-term care 

services. Medicare covers short-term skilled nursing care following a 

hospital stay. 

To qualify for Medicare or Medicaid funding, these long-term care facilities 

must meet certain federal requirements. For example, they are required to

conduct resident assessments that examine areas such as demographic 

information, cognition, mood and behavior, psychosocial well-being,

health conditions, and physical functioning. For example, the 

Preadmission Screening and Resident Review, which is required by federal 

law to determine whether the potential resident needs nursing home care, 

includes an assessment of mental capacity. Although federal regulations 

require that a resident assessment be conducted prior to admission to 

ICFs-MR, there is no standardized assessment tool and admission can be 

based on a prior assessment by an outside source. Individuals being 

admitted to an ICF-MR generally meet certain criteria, including having an

intellectual functioning level below 70 to 75 and significant limitations in 

 5

Of the 1.5 million individuals living in these long-term care facilities in 2005, about 100,000

lived in ICFs-MR. 

Page 7 GAO-06-326 Offenders in Long-Term Care Facilities
two or more adaptive skill areas.6

 In addition, at a minimum, resident 

assessments are conducted annually by nursing home and ICF-MR facility 

staff after admission in order to continually address a resident’s needs. For

each resident for whom they receive Medicare or Medicaid funding, these 

long-term care facilities are also required to develop a plan of care that

addresses the resident’s medical, social, and other needs, as determined by 

the resident assessment. Long-term care facilities are also required to 

protect residents’ rights and privacy.7

 In addition, the Privacy Rule issued 

under HIPAA provides individuals with protections regarding the 

confidentiality of their health information and restricts the use and 

disclosure of individuals’ health information by health care providers, 

including nursing homes and ICFs-MR.8

As a condition of Medicare or Medicaid participation, long-term care 

facilities must report incidents of abuse according to state requirements. 

CMS defines abuse as the willful infliction of injury, unreasonable 

confinement, intimidation, or punishment with resulting physical harm, 

pain, or mental anguish. Physical abuse generally includes hitting, 

slapping, pushing, and sexual abuse, which is nonconsensual sexual 

contact or nonconsensual sexual involvement of any kind. Although the 

commission of a sexual offense may result in an incident of abuse, a 

uniform definition of sexual offense does not exist, and states define 

sexual offenses in their respective criminal codes. Some examples of 

sexual offenses include rape, sexual assault, and incest.9

 In some states, 

related sexual offenses include child pornography and willful indecent

exposure in public. 

 6

Adaptive skills include communication, self-care, home living, and social skills. The 

criteria specify that these conditions need to have been identified at or before the age of 18. 

7

CMS sets conditions of participation for facilities that receive federal funding. Part of the 

conditions of participation requires that residents have certain rights to personal privacy

and the confidentiality of personal records. 

8

45 C.F.R. pts. 160 and 164 (2005). 

9

Rape is defined as forced sexual intercourse with a male or female victim. Sexual assault 

is defined as a variety of victimizations that involve unwanted sexual contact. Incest is 

defined as nonforcible sexual intercourse between persons who are related to each other

to a degree where marriage is prohibited by law. Department of Justice, Bureau of Justice 

Statistics, An Analysis of Data on Rape and Sexual Assault: Sex Offenses and Offenders

(Washington, D.C.: February 1997). 

Page 8 GAO-06-326 Offenders in Long-Term Care Facilities
Federal statute established the Jacob Wetterling Crimes Against Children 

and Sex Offender Registration Program in 1994.

10 The statute required 

every state to have a program to register sex offenders by September 1997, 

and required the Attorney General to provide states with guidelines for 

developing their programs.11 At a minimum, an individual convicted of a 

criminal offense against a minor or of a sexually violent offense must 

register a current address for 10 years following his/her release from 

prison or placement on parole, supervised release, or probation. In 

addition, an individual who has one or more prior sexual offense 

convictions, has been convicted of an aggravated offense, or is determined 

to be a sexually violent predator must register a current address for life.12

States may impose more stringent registration requirements on a broader

class of offenders than required by federal law. The law also mandates that 

registered sex offenders verify their addresses at least annually and that 

registered offenders classified as sexually violent predators verify their 

addresses quarterly. Registered sex offenders must notify local law 

enforcement officials within their state of address changes, and those who 

move to a different state must comply with registration requirements in 

the new state. States that do not comply with the Wetterling Program 

requirements are subject to a 10 percent reduction in their Byrne Formula 

Grant law enforcement funding.13

The statute establishing the Wetterling Program was amended twice in 

1996. The first amendment, Megan’s Law, required states to release 

information about registered sex offenders when necessary to protect the 

 10For this report, we refer to the Jacob Wetterling Crimes Against Children and Sex 

Offender Registration Program as the Wetterling Program.

11Violent Crime and Law Enforcement Act of 1994, Pub. L. No. 103-322, § 170101, 108 Stat. 

1796, 2038 (1994) (codified at 42 U.S.C. § 14071). 

12Criminal offenses against minors include criminal sexual conduct toward a minor and

solicitation of a minor to engage in sexual conduct. “Sexually violent offenses” include

offenses that consist of aggravated sexual abuse or sexual abuse. A “sexually violent 

predator” is defined as a person who has been convicted of a sexually violent offense and 

who suffers from a mental abnormality or personality disorder that makes the person likely 

to engage in predatory sexually violent offenses. 42 U.S.C. § 14071(a)(3). 

13Under the Byrne Formula Grants Program, the DOJ’s Bureau of Justice Assistance 

provides federal financial assistance to grantees for the purpose of enforcing state and

local laws that establish offenses similar to offenses established under the Controlled 

Substances Act and to improve the functioning of the criminal justice system with 

emphasis on violent crime and serious offenders. In fiscal year 2004, all 50 states, the 

District of Columbia, and the U.S. territories received financial assistance through Byrne

Grants. 

Page 9 GAO-06-326 Offenders in Long-Term Care Facilities
public, but this law did not specify how states must give notification.14 The 

second amendment, the Pam Lychner Sexual Offender Tracking and 

Identification Act of 1996,15 mandated the FBI’s creation of a national 

database now known as the NSOR.16 According to the FBI, this national 

database combines sex offender registries from all of the states to help law 

enforcement officials track sex offenders on a national level.

Research on sex offender recidivism suggests that the majority of 

individuals previously convicted of sex offenses do not commit additional 

sex offenses, with one such study estimating that about 14 percent had a 

new sex offense charge or conviction within 5 years of their release from 

prison, increasing to 27 percent after 20 years. At the same time, however, 

research also indicates that sex offenses are underreported. While it is 

difficult to predict re-offense for any individual, certain factors such as 

sexual deviancy, antisocial orientation, and an adverse family environment 

may contribute to a higher likelihood of a re-offense. Those who have 

strong social supports, such as a supportive family and a stable job, may 

be less likely to re-offend. In addition, the likelihood of re-offending may 

diminish as the sex offender ages. 

Federal law requires that registered sex offenders be tracked on a national

and state level; however, parolees are generally monitored and supervised 

by each state. Individuals released from prison prior to the completion of 

their sentences may be subject to certain conditions and supervised as 

parolees for a specified period. Typically the length of time states set for 

parole is 1 to 3 years, although certain crimes and sentencing situations 

may require more or less time. An individual can be convicted of a range of

crimes from fraud or forgery to murder and be eligible for parole. As of 

December 2003, about 775,000 adults were on parole from federal and 

state prisons nationwide.

 14Pub. L. No. 104-145, § 2, 110 stat. 1345 (1996) (codified at 42 U.S.C. § 14071). 

15For this report, we refer to the Pam Lychner Sexual Offender Tracking and Identification 

Act of 1996 as the Lychner Act.

16Pub. L. No. 104-236, § 2, 110 Stat. 3093 (1996) (codified at 42 U.S.C. § 14072). The NSOR is 

a nationwide system that links the states’ sex offender registration and notification 

programs. The system uses a person’s FBI number to connect the registration information

in the National Criminal Information Center with the registrant’s criminal history 

information that includes his/her fingerprints. According to the DOJ the NSOR should be

used to enhance a state’s ability to locate offenders in its jurisdiction who may be violating

the law by not registering. 

Page 10 GAO-06-326 Offenders in Long-Term Care Facilities
Using the NSOR, we identified 683 registered sex offenders living in longterm care facilities during 2005. However, this understates the national

prevalence of convicted sex offenders residing in long-term care facilities 

for a number of reasons. While the NSOR is a national database that 

compiles information about registered sex offenders submitted by all 

50 states and the District of Columbia, it does not include convicted sex 

offenders who are not on state registries, including those sex offenders 

who are required by law to register but choose not to comply. It also does

not include all registered sex offenders, as states have had varying degrees

of difficulty submitting their records to the NSOR because of technical 

problems, lack of resources, or inability to provide the required FBI 

number for certain offenders. Because there is no national data source on 

parolees that includes address information, we also obtained parolee 

databases from the eight states we reviewed and identified 204 offenders 

on parole for non-sex offenses living in long-term care facilities. The risk 

of abuse within nursing homes or ICFs-MR by residents with prior 

convictions is unclear because states we reviewed do not report the prior 

convictions of residents who commit abuse; however, facility 

administrators we interviewed more frequently expressed concern about 

the potential for abuse by residents with cognitive impairments or mental 

illness than by residents with prior convictions. 

Using the NSOR, we identified 683 registered sex offenders living in longterm care facilities during 2005, representing about 0.05 percent of the 

total 1.5 million residents of nursing homes and ICFs-MR. (See app. II.) Of

the approximately 16,000 nursing homes and 6,600 ICFs-MR that 

participate in Medicare or Medicaid, we identified 3 percent of nursing 

homes (470) and 0.7 percent of ICFs-MR (46) as housing at least 1 

registered sex offender during 2005. 

Identification of 

Offenders Living in 

Long-Term Care 

Facilities and 

Assessment of the 

Risk They Pose 

Limited by Data 

Shortcomings 

Most Sex Offenders 

Identified Were Male, Were 

under Age 65, and Resided 

in a Small Number of 

Nursing Homes and ICFsMR 

About 88 percent of the registered sex offenders we identified resided in 

nursing homes, while the remaining 12 percent resided in ICFs-MR. Sex 

offenders living in nursing homes were younger than the general nursing 

home population, while those in ICFs-MR had a similar age distribution as 

the general ICF-MR population. About 57 percent of registered sex 

offenders we identified as living in nursing homes were under age 65, 

compared to about 10 percent of the general nursing home population, and 

30 percent were under age 50. Most sex offenders—95 percent—identified 

as living in ICFs-MR were under age 65, which is similar to the age 

distribution in the general population of these facilities. Similarly, nearly 

all—99 percent—registered sex offenders we identified as residing in longterm care facilities were male, which is consistent with the gender of 

Page 11 GAO-06-326 Offenders in Long-Term Care Facilities
registered sex offenders overall. Among registered sex offenders for whom 

we had information on the nature of their crimes, the majority of 

convictions were for rape and sexual assault of adults and minors. 

Number of Offenders 

Identified as Living in 

Long-term Care Facilities 

Is Understated 

The number of offenders that we identified as living in long-term care 

facilities is understated because of shortcomings in the data. Specifically, 

although national in scope, the NSOR does not include certain convicted 

sex offenders who are not on state registries because the registries did not 

exist at the time they were convicted or released from prison or because 

their registration period has expired. The NSOR also does not include all 

of the records of sex offenders who are registered in the states’ registries 

because some states have had difficulty submitting their records to the 

NSOR. NSOR records for convicted sex offenders who chose not to 

comply with registration requirements may be incomplete or missing. In 

addition, since no national data source for parolees exists that includes 

parolee residence information, our data only include numbers of parolees 

from the eight states we reviewed. 

While some states already had sex offender registries in place, the 

Wetterling Program statute mandated that all states implement a registry 

by September 1997.17 Most state registries only include those sex offenders

convicted or released from prison after a specified date, generally after 

1990.

18 Consequently, those convicted or released before the specified date

were not required to register and therefore are not included in our 

analysis. This limitation may help explain the age distribution of registered 

sex offenders we identified as living in nursing homes. While the majority 

of offenders identified in nursing homes were under the age of 65, this 

could be a consequence of the limited period that sex offender registries 

have existed rather than an accurate reflection of the age distribution of 

convicted sex offenders living in nursing homes, since many elderly sex 

offenders would not be registered if their convictions predated the 

implementation of their state’s registry. 

State Registries Do Not Include 

All Convicted Sex Offenders 

 17States could apply for a 2-year extension of the statutory deadline from the DOJ if they

had made good faith efforts to comply but were unable to meet the original deadline for 

implementing a state sex offender registry. 

18Scott Matson and Roxanne Lieb, Sex Offender Registration: A Review of State Laws 

(Olympia, Wash.: Washington State Institute for Public Policy, 1996). Department of

Justice, Bureau of Justice Statistics, Summary of State Sex Offender Registries, 2001 

(Washington, D.C.: 2002). 

Page 12 GAO-06-326 Offenders in Long-Term Care Facilities
The nearly 700 registered sex offenders we identified through the NSOR 

database as living in long-term care facilities also do not include convicted 

sex offenders whose registration period expired or whose information was 

missing because they did not comply with registration requirements. While 

noncompliance is difficult to track, four of the reviewed states provided us 

with estimated noncompliance rates ranging from 4.5 percent to 

25 percent. Similarly, the advocacy organization, Parents for Megan’s Law, 

released estimates in 2003 that 24 percent of sex offenders nationally fail

to comply with registration requirements. Sex offenders may fail to 

comply for several reasons, including a lack of understanding about 

registration requirements or to avoid the possible negative consequences 

experienced by some registered sex offenders, such as the loss of a job, 

harassment, social stigmatization, or physical assault. 

We found a range of submission rates by state registries to the NSOR, 

which suggests that the NSOR may be missing a portion of sex offenders 

who are registered in states. Registry administrators from the 20 states 

that responded to our e-mail questionnaire estimated their submission 

rates to be from 46 percent to 100 percent of the total number of records 

in their state registries. Most reported that at least 80 percent of their 

records were submitted, while 2 states reported that they were only able 

to submit about half of their records. We also compared the total number 

of sex offenders included in the state registries to the number included in

the NSOR for 7 of the 8 states we reviewed. (See table 1.) The NSOR 

included about 57 percent of sex offenders registered in these states, with 

submission rates ranging from 1 to 83 percent. For example, Utah had 

submitted about 1 percent of its registry to the NSOR. While the state 

intends to fully submit its registry to the NSOR in the future, it currently 

lacks the resources to do so, according to a state official. However, the 

FBI considers state participation in the national database to be in 

compliance with federal requirements if a state has submitted at least one 

record to the NSOR.19 A DOJ official confirmed that all states have been 

determined to be in compliance with NSOR submission requirements, 

based on FBI notifications regarding each state’s participation in the 

NSOR, and was not aware of any state that had been penalized with the 

loss of Byrne Formula Grant law enforcement funding solely on the basis 

of the extent of state NSOR participation. 

State Submissions to the NSOR 

Do Not Include All Registered 

Sex Offenders 

 19An FBI official explained that the submission of one record demonstrates that the state 

has completed the reprogramming of its database to conform to NSOR standards. 

Page 13 GAO-06-326 Offenders in Long-Term Care Facilities
Table 1: Estimated Submission Rates to NSOR, by States Reviewed, 2005 

State 

Number of sex 

offenders listed on

state registry

Number of sex 

offenders listed on

NSOR, January 3, 2005 

State’s submission

rate to NSOR

(percentage)

Florida 34,810 25,494 73

Illinois 20,690 13,349 65

Minnesota a 9,769 a 

New Jersey 11,382 9,454 83

Ohiob16,864 2,409 14

Oklahoma 5,235 4,234 81

Utah 7,409 49 1

Average 57

Sources: GAO analysis of the FBI’s NSOR as of January 3, 2005; state sex offender registries as submitted by states to GAO from

January through August 2005. 

a

Minnesota initially submitted to GAO only those offenders residing in Minnesota who could potentially 

be identified as nursing home residents, which was the purpose of our request for the data, and 

therefore excluded offenders who were listed as out of state, deported, homeless, civilly committed, in

the witness protection program, or address unknown. Consequently, we could not determine an 

overall submission rate. As of February 2006, Minnesota reported that 73 percent of its active 

registrants had been accepted by the NSOR. 

b

As of January 3, 2005, Ohio had not submitted the majority of its sex offender registry because of 

technical problems, but a state official reported that the state submitted registry data on computer 

disk in August 2005. 

Registry administrators from among the 8 states we reviewed and the 20 

additional states that responded to our e-mail questionnaire reported that

several factors complicate their efforts to submit complete sex offender 

registries to NSOR. For example, registry administrators frequently 

responded that they were not able to submit records of registered sex 

offenders who did not have FBI numbers. FBI numbers are required by the 

FBI for all records submitted to the NSOR to ensure positive identification 

of individuals for the purposes of employment background checks.20 States 

may lack FBI numbers for several types of offenders, such as juvenile sex

offenders who do not receive FBI numbers or sex offenders from other 

states. If a sex offender comes from out of state, his/her FBI number can 

 20Under the Lychner Act, NSOR information must also be disclosed for employment 

background checks. To ensure that information released in background checks is accurate, 

a person’s identification is verified using fingerprints. The FBI number provides the 

necessary link between the sex offender registry record and an offender’s fingerprint 

records to technically achieve the inclusion of an offender’s NSOR records in employment 

background checks. 

Page 14 GAO-06-326 Offenders in Long-Term Care Facilities
be obtained from the state where the conviction occurred, but it can be

labor-intensive if the other state does not cooperate or never submitted 

fingerprint information to establish the offender’s FBI number.21 Registry 

administrators in two of the states we reviewed estimated that in recent 

years about 30 percent of the records they submitted to the NSOR were 

rejected as incomplete.22 In addition, states are required to verify 

information, including home address, for each registered offender at least 

annually and quarterly for registered offenders classified as sexually 

violent predators, a process that can also be labor-intensive.23 If states are 

unable to verify an offender’s address information, the offender should be 

considered noncompliant, and the NSOR record will not be up-to-date nor 

reflect current address information. Some states have also experienced 

technical difficulties submitting their registry records to the NSOR. An FBI 

official told us that states that had registries prior to the creation of the 

NSOR had difficulty reprogramming their registry databases to conform to 

the NSOR formats. One of the states we reviewed did not realize until 2005

that only a fraction of its records were being submitted to the NSOR 

because of a technical problem, and it is currently submitting records on 

computer disks while making plans to implement a system for automatic 

electronic submission of its full sex offender registry to the NSOR. 

Although the FBI does not track states’ submission rates to the NSOR, it 

does periodically assess state participation in the NSOR and provides 

assistance to help states improve the comprehensiveness and accuracy of

their registries. In addition to the requirement that states annually validate 

registry records, we were informed that the FBI conducts triennial audits

of states’ participation in the NSOR. During fiscal year 2005, the FBI also 

conducted a fiscal audit, assessed states’ level of participation in the NSOR 

and requested information from states about what assistance they need to

 21States also have the option of searching for an offender’s FBI number by conducting

inquiries of the FBI’s Fingerprint Identification Record System using name and date of birth

or fingerprints.

22According to NSOR data documentation provided by the FBI certain pieces of 

information are mandatory for state registry records to be accepted into the NSOR, 

including: offender’s name; physical characteristics, including gender, height, weight, eye,

and hair color; race; date of birth; registration beginning and ending dates; FBI number; and 

conviction information. The NSOR also includes other information, such as vehicle license 

plate numbers and home address, but will accept records even if this information is not

provided. 

23In addition to annual address verification, states are required to validate information in 

the NSOR on an annual basis to ensure the accuracy and completeness of the information. 

Page 15 GAO-06-326 Offenders in Long-Term Care Facilities
improve their participation. DOJ provides grants to help states improve 

their law enforcement information systems, which states have utilized for

enhancements to their sex offender registries such as enabling the 

automatic transmission of records to the NSOR and for monitoring data 

accuracy. DOJ informed us that it also provides training and technical 

assistance to states, and that the FBI has an advisory group that is 

reviewing issues such as state submission of data to the NSOR and the 

process for the verification and validation of NSOR records. 

Using data provided by each of the eight states we reviewed, we identified

204 parolees as residents of long-term care facilities. (See table 2.) 

Because there is no national source of data on parolees that includes their 

home address information, our numbers are limited to the eight states and 

cannot be generalized as representative of all states. Among parolees for 

whom we had information on the nature of their crimes, the convictions 

were most commonly for burglary, assault, murder, or drug-related 

offenses. 

Approximately 200 Parolees 

Identified as Living in Longterm Care Facilities in Eight 

States 

Table 2: Parolees Identified as Living in Long-term Care Facilities in States 

Reviewed, 2005 

State Nursing homes ICFs-MR Total

a

California 63 4 67

Florida 7 0 7

Illinois 70 4 74

Minnesota 2 0 2

New Jersey 2 1 3

Ohio 42 1 43

Oklahoma 6 0 6

Utah 2 0 2

Total 194 10 204

Sources: GAO analysis of parolee databases for eight reviewed states, January through September 2005; CMS’s OSCAR database,

2004. 

a

Results do not include parolees who were also listed on state sex offender registries or the NSOR. 

Page 16 GAO-06-326 Offenders in Long-Term Care Facilities
Long-term care facilities participating in Medicare or Medicaid are 

required to report all allegations of abuse and neglect to officials in 

accordance with applicable state law and, in the case of nursing homes, 

this includes reporting to the state.24 This requirement would encompass 

the reporting of abuse committed by staff or residents. In the eight states 

we reviewed, long-term care facilities do stratify reported abuse into 

categories, such as physical, sexual, financial, or resident-to-resident 

abuse; however, they do not report information on whether residents 

alleged to have caused abuse have prior convictions. The National 

Ombudsman Reporting System (NORS) also collects nursing home abuse 

data on a national level and includes various categories of abuse, such as 

incidents that occur between residents and incidents perpetrated by 

nursing home staff. Similar to the states we reviewed, NORS does not 

track whether residents alleged to have abused other residents have prior 

convictions.

Abuse by Offenders Who 

Live in Long-term Care 

Facilities Not Tracked, but 

Risk May Not Be 

Widespread 

Because data are not available nationally or in our reviewed states on 

abuse perpetrated specifically by residents who have prior convictions, 

the potential risk for abuse by offenders residing in long-term care 

facilities cannot be accurately estimated. However, based on a number of 

factors, including the small percentage of facilities identified as housing 

offenders, the risk may not be widespread. For example, offenders 

residing in nursing homes or ICFs-MR who have significant physical 

limitations may be unable to commit abuse against other residents. In 

addition, research on recidivism by sex offenders also suggests that most 

do not re-offend and that the risk of re-offending may decline with age. 

In our interviews with officials of long-term care facilities, state nursing 

home associations, and state ombudsmen for long-term care, concern was 

more frequently expressed about the behavior and potential for abuse by 

cognitively impaired and mentally ill residents than about abuse by 

residents with prior convictions. Several of those interviewed mentioned 

they were concerned about the potential for abuse by residents with 

Alzheimer’s disease or dementia, a disease for which their behavior may 

change significantly after their admission and original assessment. The 

administrator of a facility in Ohio that specializes in residents with 

behavioral issues and that has housed multiple offenders said that he has 

had fewer problems with his residents who are identified sex offenders 

than with other residents who have behavioral problems. Several sources, 

 2442 C.F.R. §§ 483.13(c)(2), 483.420(d)(2). 

Page 17 GAO-06-326 Offenders in Long-Term Care Facilities
including ombudsmen, a researcher, and a nursing home advocate, 

suggested that a resident’s behavioral issues are sometimes not fully 

disclosed to a nursing home upon admission or that some nursing homes 

with low occupancy may be more likely than others to accept mentally ill 

patients in order to increase their occupancy levels. 

Long-term care facility officials we interviewed, some of whom knew they 

have had offenders as residents and some of whom spoke hypothetically,

said they would use their judgment to determine whether a registered sex 

offender or parolee could appropriately be cared for in their facilities. 

Several long-term care facility administrators told us that if they 

discovered a resident was an offender, they would evaluate the potential

risk posed by that individual on a case-by-case basis. For example, the 

facility administrator may determine the degree of safety risk on the basis 

of whether the offender’s health status is such that the individual cannot 

move independently. If the administrator determines that the risk is 

greater than the long-term care facility can manage, the facility may 

choose not to admit the offender. 

Federal law requires state law enforcement agencies to release relevant 

information about registered sex offenders when necessary to protect the 

public, but we did not identify a similar federal requirement pertaining to 

the parolee population. The federal requirement for registered sex 

offender notification allows states to implement this requirement at their 

discretion, within broad federal guidelines. Consequently, the extent to

which states’ community notification laws apply to all registered sex 

offenders or explicitly include nursing homes and ICFs-MR varies. Absent 

direct notification, these facilities may not know they house offenders or 

may only become aware of offenders through other means. For example, 

in the case of registered sex offenders, facilities may identify some 

offenders by reviewing publicly available Web sites, while for parolees, 

they may become aware of the person’s criminal background from a 

parole officer. When facility residents are known offenders, differing 

interpretations exist among states, industry, and long-term care facility 

officials as to whether sharing information about their prior convictions 

may violate the Privacy Rule issued by HHS under HIPAA. 

States Required to 

Notify Community 

about Registered Sex 

Offenders, but Extent 

of Notification Varies 

Page 18 GAO-06-326 Offenders in Long-Term Care Facilities
Megan’s Law, a 1996 amendment to the Wetterling Program statute, 

required each state to release information about registered sex offenders 

when necessary to protect the public. The law applied specifically to 

registered sex offenders and not to convicted sex offenders who were not 

obligated to register.25 Although Megan’s Law stipulated that information 

about the victims of registered sex offenders was not to be released, it 

otherwise did not specify the information to be disseminated about 

registered sex offenders, did not mandate that community notification be 

uniform for all registered sex offenders, and did not specify how states 

were to release information. 

Federal Law Requires 

States to Provide 

Community Notification 

for Registered Sex 

Offenders, but Direct 

Notification to Long-term 

Care Facilities Varied 

Consequently, states’ community notification laws vary, particularly in 

terms of the extent to which notification by law enforcement entities 

applies to all registered sex offenders. Such variation was evident in the 

notification laws of the eight states we reviewed. While two states we 

reviewed—Illinois and Utah—apply community notification requirements 

to all registered sex offenders uniformly in each state,26 the community 

notification requirements in the remaining six states—California, Florida,

Minnesota, New Jersey, Ohio, and Oklahoma—vary depending on the 

crime committed by the registered sex offender.27 For example, New 

Jersey classifies its registered sex offenders into three categories based on

their assessed risk of re-offending. For sex offenders determined to be 

lowest risk, state law requires notification of law enforcement agencies. In

contrast, for the highest risk sex offenders, the law requires notification of

additional entities, including schools, religious and youth organizations, 

and those likely to encounter the offender. Similarly, Florida’s law 

explicitly requires broad community notification when individuals 

designated to be sexual predators reside in the community, but it does not 

require broad notification for other sex offenders. 

Variation also exists in the extent to which state community notification 

laws explicitly require the notification of long-term care facilities. Four 

states we reviewed—California, Illinois, Minnesota, and Oklahoma—

 25The federal law requires the registration of sex offenders convicted of criminal offenses 

against minors or of sexually violent offenses or those designated as sexually violent 

predators. 

26730 ILCS Stat. Ann. § 152/120 (West 2005); Utah Code Ann. § 77-27-21.5 (2003). 

27Cal. Penal Code § 290.45 (Dearing 2005); Fla. Stat. Ann. § 944.606 (West 2005); Minn. Stat. 

Ann. § 244.052 (West 2003); N.J. Stat. Ann. § 2C: 7-8 (West 2005); Ohio Rev. Code Ann. §§

2950.081, 2950.11 (Anderson 2005); Okla. Stat. Ann. Tit. 57, § 584 (West 2005-2006). 

Page 19 GAO-06-326 Offenders in Long-Term Care Facilities
passed laws in summer and fall 2005 that specified long-term care facilities 

as entities to be notified for at least some registered sex offenders who 

entered them.28, 29 Notification in these states is conducted by individual 

facility officials, state or law enforcement officials, or registered sex 

offenders themselves. For example, Illinois’ law requires long-term care 

facilities to determine whether each resident or potential resident is a 

registered sex offender and to notify staff, residents or their legal 

guardians, and facility visitors when offenders are residents.30 Similarly, 

Oklahoma’s law requires notification of these facilities by several methods. 

For example, the Department of Corrections must notify the Department 

of Health when any person in its custody seeks placement in these 

facilities, and the Department of Health must then notify the facility of the 

potential for the placement of a registered sex offender. When residents 

are determined to be registered sex offenders, information about them 

must be displayed in the facility in an area that is accessible to staff, 

visitors, and residents. The law in California also requires state officials to

notify long-term care facilities when registered sex offenders are released 

to them from the Department of Corrections and Rehabilitation, the State 

Department of Mental Health, or other state-operated places of 

confinement. The law does not provide for such notification when sex 

offenders enter long-term care facilities from the community. Unlike other 

states we reviewed, Minnesota’s law requires registered sex offenders to 

disclose their status if seeking admission to long-term care facilities. Upon 

receiving such notification from certain registered sex offenders, longterm care facilities are responsible for sharing this information with other 

residents or their legal guardians. Minnesota also requires law 

enforcement officials to notify health care facilities if they become aware 

that a registered sex offender has been admitted for care. 

 282005 Cal. Adv. Legis. Serv. c. 466 (Dearing); 2005 Ill. Legis. Serv. 94-163 (West); 2005 Minn. 

Laws c. 243.166; 2005 Okla. Sess. Laws Serv. c. 465 (West). 

29Requirements in state community notification laws specifying that nursing homes and 

ICFs-MR be notified about registered sex offenders who were residents appear to be a 

recent trend. For example, a 2001 review of state community notification laws by the

Bureau of Justice Statistics found that states generally did not notify nursing homes or

ICFs-MR when offenders entered the facilities.

30Emergency rules implementing this law require licensed long-term care facilities, such as 

nursing homes and ICFs-MR, to check the background of potential residents through the 

state sex offender database. 77 Ill. Reg. § 300.625 (as added for emergency rules published

on Sept. 2, 2005). These rules expired on December 7, 2005, and have not yet been replaced 

by permanent rules.

Page 20 GAO-06-326 Offenders in Long-Term Care Facilities
The other four states we reviewed—Florida, New Jersey, Ohio, and Utah—

do not specifically require the notification of long-term care facilities when 

registered sex offenders enter them. Long-term care facilities in these 

states, or in states where community notification of such facilities is not 

required for all registered sex offenders, may not be aware of residents 

who are offenders or must rely on other methods to identify such 

individuals. For instance, administrators we interviewed at 8 of the 

29 long-term care facilities indicated that one or more registered sex 

offenders had lived in their facilities for some period. Each of these 8 longterm care facilities was notified about the registered sex offenders, 

although the method of notification varied. For example, while 4 facilities

were notified before the offenders entered them, either by offenders’ 

family members or the state department of corrections, the 4 remaining 

facilities were notified after the registered sex offenders were admitted, 

either by local law enforcement officials who were verifying sex offenders’ 

residential addresses or by an advocacy group conducting research on 

registered sex offenders living in certain long-term care facilities. 

Long-term care facilities may access states’ publicly available sex offender 

registry Web sites to determine where registered sex offenders reside. A 

2003 amendment to the Wetterling Program statute required states to 

maintain a publicly available Web site with information about registered 

sex offenders.

31 The law did not provide instruction on how these Web 

sites should be designed or what specific information should be included.

32

Depending on the state, these Web sites provide varying amounts of 

information to the public about registered sex offenders. For example, the 

Web site registry in each of the eight states we reviewed included some 

address information for all or a portion of the state’s adult registered sex 

offenders. Five states we reviewed—Florida, Illinois, Ohio, Oklahoma, and 

Utah—provided the full residential address of all the state’s adult 

registered sex offenders, while three others—California, Minnesota, and 

New Jersey—included certain registered sex offenders on their Web sites 

and in some cases did not always list their full addresses. For example, 

Minnesota separates offenders into three levels and includes Level 3 

offenders—those deemed predatory or most likely to re-offend—on its 

Web site. Approximately 6 percent of the registered sex offenders in this 

 31The Prosecutorial Remedies and Other Tools to End the Exploitation of Children Today 

Act of 2003, Pub. L. No. 108-21 § 604, 117 Stat. 650, 688.

32DOJ has published proposed guidelines in the Federal Register with respect to state 

Internet sites for sex offender information at 70 Fed. Reg. 12721 (2005). 

Page 21 GAO-06-326 Offenders in Long-Term Care Facilities
state who are living in the community are assigned the highest risk level. 

Similarly, New Jersey includes certain moderate and all high-risk 

registered sex offenders on its Web site, which, according to a state 

official, represents about 16 percent of all registered sex offenders in the 

state. In California, a state official told us that its Web site registry 

includes at least some address information for approximately 74 percent

of the state’s registered sex offenders, including full address information 

for about 57 percent who committed crimes considered to be the most 

serious. The remaining approximately 26 percent of the state’s registered 

sex offenders are not posted on the Web site because they committed less 

severe offenses or are excluded from the Web site for various reasons, 

such as not being designated sexually violent predators. In addition, for 

the registered sex offenders listed on the Web sites of the eight states we 

reviewed, information is included about the crimes registered sex 

offenders committed; their names, nicknames, or aliases, when applicable; 

date of birth or age; and race or ethnicity. 

While the NSOR database is not directly accessible by the general public,

long-term care facilities can access the recently developed National Sex

Offender Public Registry maintained by the DOJ.33 This Web site, which 

was first launched in May 2005, seeks to compile public sex offender 

registry information available through state Web sites, and as of January 

2006, it included public registry data from all but two states. Although this

Web site provides the public with one-stop access to states’ online sex 

offender registries, it may be of limited usefulness because states’ sex 

offender registry Web sites, as described above, do not always include a 

comprehensive list of registered sex offenders. 

Although Community 

Notification of Parolees 

Not Uniformly Required, 

Parolees in Long-term Care 

Facilities Often Identified 

by Law Enforcement 

We did not identify a federal law specifying community notification 

requirements for law enforcement when parolees enter the community 

that was similar to the federal law for registered sex offenders. However, 

three of the eight states we reviewed—Illinois, Minnesota, and 

Oklahoma—passed laws in summer 2005 that require community 

notification for offenders who have committed crimes other than sex 

offenses, including some offenders who are parolees.34 Illinois’ law 

requires the state Department of Corrections to give some information to 

 33See http://www.nsopr.gov/.

342005 Ill. Legis. Serv. 94-163 (West); 2005 Minn. Laws c. 243.166; 2005 Okla. Sess. Laws 

Serv. c. 465 (West). 

Page 22 GAO-06-326 Offenders in Long-Term Care Facilities
certain long-term care facilities when parolees or certain other offenders 

become residents. In addition, these long-term care facilities are required 

to notify the other residents when parolees reside in their facilities. In 

Minnesota and Oklahoma, long-term care facilities receive community 

notification for some individuals convicted of non-sex offenses, including 

some parolees, under the same requirements as those for registered sex 

offenders. Minnesota’s law applies to individuals convicted of some 

crimes, including murder or kidnapping. Oklahoma’s law requires 

notification for individuals who are required to register under the Mary 

Rippy Violent Crime Offenders Registration Act, which includes 

individuals convicted of crimes such as murder or manslaughter in the 

first degree.

Department of Corrections’ officials or other authorities in each of the 

eight states we reviewed stated that as a matter of practice, they generally 

notified long-term care facilities when individuals released from prison, 

including parolees, are placed in such facilities. For example, according to

officials in Ohio’s Department of Rehabilitation and Corrections, when an 

inmate who needs long-term care is paroled, a parole officer works with 

the facility to ensure that medical records are transferred and that a plan 

of care is established to meet the needs of the parolee. 

Officials Uncertain about 

Ability of Long-term Care 

Facilities to Disclose 

Offender Information 

under the HIPAA Privacy 

Rule 

While the HIPAA Privacy Rule applies to individually identifiable health

information, differing interpretations exist among state, industry, and longterm care facility officials we interviewed in the eight states regarding the 

applicability of the rule to facilities’ efforts to notify others about residents 

who have prior convictions, such as those who are registered sex 

offenders or parolees. These difficulties existed regardless of whether this 

information was obtained from a medical record or in another way, such 

as from a law enforcement official. For instance, long-term care agency 

officials from three states we reviewed indicated that protection of health 

information under the HIPAA Privacy Rule did not extend to information 

on prior convictions. In addition, long-term care facility and other agency 

officials from these and three other states we reviewed maintained that it 

was permissible to disclose information about a resident’s prior 

convictions to employees in a long-term care facility who needed to know 

in order to provide care for the resident. Yet other officials in six of the 

eight states we reviewed told us they were either unsure whether the 

HIPAA Privacy Rule would be violated by sharing information about the 

prior convictions of any offender living in a facility or that they believed

the HIPAA Privacy Rule did not apply to disclosing such information about 

residents who are offenders. Officials at 11 of the 29 long-term care 

Page 23 GAO-06-326 Offenders in Long-Term Care Facilities
facilities we interviewed in eight states said that they were concerned they 

would violate the HIPAA Privacy Rule if they disclosed information about 

the prior convictions of offenders living in their respective facilities, but 

indicated that they would notify staff if they became aware of such 

residents. 

We brought the issue of long-term care facilities’ uncertainty regarding the 

applicability of the HIPAA Privacy Rule to the attention of an official of the 

Department of Health and Human Services Office for Civil Rights (HHSOCR), the federal entity responsible for implementing and enforcing the 

HIPAA Privacy Rule. The official indicated that HHS-OCR has not 

published regulations or other guidance specifically regarding the 

applicability of the HIPAA Privacy Rule to the disclosure of information 

related to prior convictions of long-term care facility residents. However, 

the official stated that to the extent that such information is maintained by

long-term care facilities as protected health information under the HIPAA 

Privacy Rule, such information could be used or disclosed for specifically

permitted purposes, such as when necessary to run the health care 

operations of a facility or required by another federal or state law. In 

addition, the HHS-OCR official indicated that affected entities, such as 

long-term care facilities, would need to make the determination on a caseby-case basis as to whether the information is protected health 

information, and if so, whether its intended use or disclosure is permitted 

by the HIPAA Privacy Rule. The official added that long-term care facilities 

should consult their legal counsel if they have questions in making this 

determination. Although HHS-OCR does maintain a list of answers to 

frequently asked questions about the HIPAA Privacy Rule on its Web site, 

it does not cover this specific issue. In commenting on a draft of this 

report, Department of Corrections officials from one state we reviewed 

stated that it would be helpful for HHS-OCR to describe some situations in 

which it believes HIPAA would not be applicable with regard to the 

disclosure of information about offenders admitted to health care 

facilities. They stated that HHS-OCR’s direction to approach each case 

individually is not very helpful and that additional guidance would be very 

useful. 

Page 24 GAO-06-326 Offenders in Long-Term Care Facilities
Residents’ prior convictions alone would not be sufficient in most cases to 

subject them to supervision or separation requirements that differed from 

other residents, according to facility officials we interviewed.

Administrators at only 2 of the 29 long-term care facilities we contacted 

indicated that they have a specific policy to separate offenders from other 

residents based solely on their prior convictions. Instead, long-term care 

facilities in the eight states we reviewed typically base supervision and 

separation decisions on behavioral issues that arise. For example, in the 

states we reviewed, several long-term care ombudsmen, industry 

association officials, and facility officials we interviewed indicated that the 

residents they have particular concerns about, in terms of behavioral 

problems, are those with mental illness, such as dementia, for which 

behaviors are apt to change as the disease progresses. 

Supervision and 

Separation of LongTerm Care Facility 

Residents Largely 

Based on Behavior, 

Not Prior Convictions 

Although most officials we spoke with at long-term care facilities in the 

eight states we reviewed do not supervise or separate offenders based 

solely on their prior convictions, some officials indicated the potential for

a future need for residential facilities separate from long-term care 

facilities exclusively for certain offenders. For instance, Minnesota state 

officials said that some long-term care facilities may be hesitant to accept 

sex offenders as residents in the future, believing that certain sex 

offenders pose a risk to the safety of other residents. Therefore, a state 

commission has recommended the development of secure health care 

settings that would serve people who have committed certain sex offenses 

and who may not otherwise have access to services. In order to establish 

this facility, state officials are working with federal officials to resolve 

issues related to balancing resident rights with the safety interests of the 

larger community. 

Even if long-term care facility officials wanted to impose different 

supervision and separation requirements on offenders, numerous factors 

could affect their ability to do so. For example, as previously noted, longterm care facilities were not always notified when individuals with prior 

convictions entered them. Federal laws we reviewed do not require longterm care facilities to obtain information about prior convictions, and 

among the eight states we reviewed, only Illinois had such a requirement.35

In addition, assessment tools long-term care facilities in these eight states 

 3577 Ill. Reg. §§ 300.615, 300.625 (as added by emergency rules published Sept. 2, 2005).

These rules expired on December 7, 2005, and have not yet been replaced by permanent

rules. 

Page 25 GAO-06-326 Offenders in Long-Term Care Facilities
use to determine the health care needs of residents usually are not 

designed to gather information about prior convictions. Even if facilities 

obtained such information, federal and state laws that we reviewed 

generally do not provide for specific supervision or separation practices 

for facility residents with prior convictions. 

Each incident of resident abuse committed by offenders living in nursing 

homes—even if isolated or infrequent—is of concern. However, while 

long-term care facilities may learn that certain of their residents are sex 

offenders or parolees through required community notification or through 

other means, our findings did not indicate that residents with prior 

convictions are more likely than other residents to commit abuse within 

these facilities. Absent such evidence, it may be more appropriate to focus 

on residents’ behaviors versus their prior convictions when assessing the 

potential for committing abuse. Facility officials we interviewed more 

frequently expressed concerns about the behavior and potential for abuse 

by cognitively impaired and mentally ill residents than by offenders who 

may have no behavioral issues. Facilities already document problematic 

behaviors and assess the risk of individuals through resident assessments 

and care planning procedures, and when they accept residents with 

behavioral issues or such issues arise after admission, they must 

appropriately address those behaviors through the care planning for these 

individuals or transfer them to facilities better equipped to handle such 

residents. In addition, focusing on prior convictions alone can be 

problematic in that some offenders, such as those with certain physical 

impairments, likely do not pose a risk to other residents. Nonetheless, in 

the interest of identifying potential risks and taking precautionary 

measures, four states we reviewed—California, Illinois, Oklahoma, and 

Minnesota—enacted measures in 2005 to require notification to long-term 

care facilities when offenders are residents. Assessing their experiences as 

they implement these measures over time, including any negative impact 

on offenders’ access to long-term care, may be instructive for other states 

with similar concerns. 

Conclusions 

While it was not part of our original objectives to fully evaluate the NSOR, 

it was our primary data source for identifying registered sex offenders 

residing in long-term care facilities. In the course of our analysis, we 

became aware that the FBI’s NSOR, which links states’ sex offender 

registration programs so that law enforcement agencies can identify sex 

offenders regardless of which state maintains their registration, was 

incomplete for the seven states we reviewed for this purpose. States face

various barriers to fully submitting their registry records to the NSOR, 

Page 26 GAO-06-326 Offenders in Long-Term Care Facilities
including difficulties such as obtaining the required FBI number for each 

offender and a lack of staff resources. While the FBI has been reviewing 

issues related to states’ submission of records to the NSOR, it currently 

does not track submission rates, so the proportion of state records missing 

from the NSOR is not precisely known. Continued improvements in the 

comprehensiveness of the NSOR can enhance the ability of local law 

enforcement agencies to identify offenders and notify the community, 

including long-term care facilities, where appropriate. 

We recommend that the Attorney General direct the FBI to take the 

following two actions: 

• assess the completeness of the NSOR, including state submission rates, 

and 

• evaluate options for making it a more a comprehensive national database 

of registered sex offenders. 

We provided copies of a draft of this report for comment to DOJ; HHS; and 

the eight states we reviewed: California, Florida, Illinois, Minnesota, New 

Jersey, Ohio, Oklahoma, and Utah. We received written responses from 

DOJ and HHS, which are included in this report as appendixes III and IV, 

respectively. We also received comments from California, Florida, Illinois, 

Minnesota, New Jersey, and Oklahoma. These agency and state comments 

and our evaluation follow. 

DOJ commented that the recommendations are unnecessary because the 

FBI already performs assessments of the NSOR and explores options for 

improvement. For example, DOJ said that the FBI conducts triennial 

audits of states’ NSOR participation, provides training and technical 

assistance to states, and seeks input from states about what assistance 

they need to improve their level of participation in the NSOR. DOJ 

characterized our evaluation as incomplete because we did not ask for 

information about the entire NSOR program or include a more extensive 

discussion in the draft report of their efforts to improve the NSOR. We 

obtained information about these efforts over the course of our work 

through interviews with FBI staff, documents available on their Web site, 

and through state officials. Because a comprehensive evaluation of the 

NSOR was not one of our reporting objectives, we did not include a 

complete listing of the FBI’s assistance to states in our draft report. To 

respond to DOJ’s comments, we revised the report to include additional 

information about the FBI’s initiatives to assist states in data submission 

Recommendations for 

Executive Action 

Agency and State 

Comments and Our 

Evaluation 

Page 27 GAO-06-326 Offenders in Long-Term Care Facilities
and to assess the accuracy of NSOR records. Including this additional 

information, however, does not alter our overall finding concerning the 

discrepancy between state sex offender registries and states’ NSOR 

submissions. 

We acknowledge, as DOJ pointed out in its comments, that there may be 

valid reasons for a certain amount of discrepancy between state registries 

and their NSOR submissions, such as if a state chooses not to submit the 

records of sex offenders still incarcerated since their whereabouts do not 

need to be tracked by the NSOR until their release. We also acknowledge 

the challenge states face in maintaining current and accurate information 

about registered sex offenders. However, we continue to believe that the 

intent of the recommendations remains valid because of the evidence we 

analyzed for a sample of states that a significant percentage of registered 

sex offender records are not being successfully submitted by some states 

to the NSOR, despite the states’ and FBI’s efforts to date. We believe the 

FBI needs to track state submission rates to the NSOR as a measure of 

comprehensiveness that can quantify the remaining gap as well as 

improvements over time. We therefore revised the first recommendation 

to specify that we are recommending that the FBI assess state submission 

rates as a means of assessing the completeness of NSOR. 

DOJ commented on three additional issues: 

• The risk posed by offenders residing in long-term care facilities. 

DOJ suggested that GAO discounted the risk posed by sex offenders 

residing in long-term care facilities based on insufficient evidence. We 

agree that the placement of a sex offender into a long-term care facility 

requires careful evaluation, particularly as the often-frail condition of longterm care residents makes them vulnerable to victimization. Based on our 

research and interviews with administrators of long-term care facilities, it 

is our view that the risk posed by offenders should be considered on a 

case-by-case basis. The presumption that offenders pose a threat to other 

residents could lead facilities to unnecessarily deny admission to low-risk 

offenders or unnecessarily seclude them from other residents. DOJ did not 

provide any new evidence to support its assertion that sex offenders pose 

a greater threat than the analysis we presented in the report. 

• The likelihood that convicted sex offenders will commit additional 

sex offenses after their release from prison. DOJ objected to our 

citation of sex offender recidivism rates of 14 percent because they were 

based on only a 5-year post-incarceration period, saying the period was 

too short to be the basis of inferences about the likelihood that a sex 

offender will commit additional sex offenses, and because of evidence that 

Page 28 GAO-06-326 Offenders in Long-Term Care Facilities
sex offenses are underreported. We revised the report to clarify that the 

same research also cites 20-year sex offender recidivism rates of 

27 percent. 

• The usefulness of the NSOR in assisting law enforcement to 

identify sex offenders residing in long-term care facilities. DOJ 

questioned GAO’s assertion that improvements in the comprehensiveness 

of the NSOR would improve the ability of local law enforcement to 

identify sex offenders residing in nursing homes, commenting that 

offenders would either already be on the state registry and thus 

identifiable or they would not be registered and therefore not included in

the NSOR. We believe that a more comprehensive NSOR would improve 

the tracking of sex offenders who enter long-term care facilities in the 

same way it improves the tracking of sex offenders generally. If offenders 

are registered in one state but move to another state and fail to register, 

their records could be in the NSOR from the original state but not on the 

registry of the second state. A more comprehensive NSOR thus better 

ensures the national tracking of sex offenders who may choose to cross 

state lines. 

HHS commented that this report brought to its attention the uncertainty 

that some long-term care facility officials have about the application of the 

HIPAA Privacy Rule to the disclosure of conviction information, as well as 

the issue that future guidance may be needed. HHS commented that the 

report will help to resolve the uncertainty about the HIPAA Privacy Rule, 

including clarifying that disclosures could be allowed for activities 

necessary for the safe operation of the facility or as required by state laws. 

DOJ, HHS, and the states also provided technical comments, which we 

incorporated as appropriate. 

As arranged with your offices, unless you publicly announce the contents 

of this report earlier, we plan no further distribution of it until 30 days 

after its issue date. At that time, we will send copies to the Attorney 

General, the Secretary of Health and Human Services, and other interested

parties. We will also make copies available to others upon request. This 

report is also available at no charge on GAO’s Web site at 

http://www.gao.gov. 

Page 29 GAO-06-326 Offenders in Long-Term Care Facilities
If you or your staffs have any questions about this report, please contact 

me at (202) 512-7118 or allenk@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. GAO staff who made major contributions to this report are 

listed in appendix V. 

Kathryn G. Allen 

Director, Health Care 

Page 30 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix I: Scope and Methodology Appendix I: Scope and Methodology 

To determine the prevalence of registered sex offenders residing in longterm care facilities nationwide, we matched the addresses of registered 

sex offenders listed in the Federal Bureau of Investigation’s (FBI) National 

Sex Offender Registry (NSOR) as of January 3, 2005, with the addresses of 

nursing homes and intermediate care facilities for people with mental 

retardation (ICF-MR) listed in the Centers for Medicare & Medicaid 

Services’ (CMS) Online Survey, Certification and Reporting system 

(OSCAR) database. After standardizing address spellings and 

abbreviations, we used SAS, a statistical analysis program, to compare 

registered sex offender and long-term care facility addresses. Using a SAS 

function that quantifies the magnitude of difference between two text 

variables, we identified exact matches as well as near matches where the 

addresses differed slightly. We manually reviewed the addresses that 

differed slightly to determine if they were the same address. 

To evaluate the comprehensiveness of the NSOR, we requested the full 

state sex offender registries from 8 states—California, Florida, Illinois, 

Minnesota, Ohio, Oklahoma, New Jersey, and Utah—in order to compare 

the number of records in each registry to the number of records in the 

NSOR for that state. We chose these 8 states on the basis of a number of 

criteria, including variation in geographic location and in the number of 

registered sex offenders identified as living in long-term care facilities 

based on our preliminary analyses. California state officials did not 

provide us with the state’s sex offender registry in view of their concerns

with state privacy laws. We also interviewed FBI staff about the 

management of the NSOR database. To obtain information about the 

administration and content of state registries, including their submission 

of records to the NSOR, we interviewed state registry administrators from 

the 8 states we reviewed and submitted a questionnaire via e-mail to the 

remaining 42 states, receiving responses from 20 of them. 

Since no national data source on parolees that includes address 

information exists, we obtained parolee databases from each of the eight 

states we reviewed. We matched parolee addresses to nursing homes and

ICFs-MR in OSCAR using the same methods we used for our analysis of 

NSOR and state sex offender registries. 

We excluded some records from our analysis because there was no valid 

domestic address for the offender. Table 3 shows the number of records 

we analyzed from all data sources for both registered sex offenders and 

parolees, and the number of records excluded from each source because 

of missing, invalid, or otherwise unusable address information. 

Page 31 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix I: Scope and Methodology 

Table 3: Validity of Offender Address Data by Data Source 

NSOR 

Parolee data from eight

reviewed states 

Validity of offender 

address data 

Number of 

records

Share of

total 

Number of 

records

Share of

total

State abbreviation 

does not match one of 

50 states or 

Washington, D.C. 27,141 7% - -

Offender incarcerated 

or deported 23,863 6% 529 0%

Offender transient, 

homeless, or address 

unknown 5,936 2% 1,653 1%

Address listed is invalid 8,775 2% 11,879 5%

City/state does not 

match zip code 327 0% 12 0%

Valid address 304,489 82% 248,290 95%

All 370,531 100% 262,363 100%

Sources: GAO analysis of the NSOR, 2005; GAO analysis of parolee databases for eight reviewed states obtained March through

September 2005. 

To obtain information about resident abuse perpetrated by registered sex 

offenders and parolees, we reviewed existing research and prior GAO 

reports. We also interviewed long-term care facility administrators in the 

eight states we reviewed, including administrators at facilities with 

registered sex offenders as residents, as well as state department of health

and industry association officials and ombudsmen. To identify facilities for 

administrator interviews, we initially chose four long-term care facilities in

each of the eight states we reviewed. These facilities were chosen from 

two groups of facilities based on our initial analysis of NSOR and OSCAR 

data. One group comprised facilities with registered sex offender matches 

and the other group did not have any such matches, and when possible, we 

selected two facilities from each grouping. If a selected facility refused our 

request for an interview, we selected another facility as a replacement 

from the same group. If a state did not have enough facilities with or 

without sex offenders to complete two interviews from each group of 

facilities, we used facilities from the other group. In all, we interviewed 

administrators at 29 long-term care facilities, 11 with registered sex 

offender matches and 18 without matches. We achieved a 91 percent 

response rate for the facility interviews. 

Page 32 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix I: Scope and Methodology 

To determine whether federal laws provide for notification of facility staff, 

residents, and residents’ families when sex offenders or parolees live in 

long-term care facilities or for the supervision and separation of sex 

offenders and parolees living in these facilities, we reviewed federal laws 

and interviewed Department of Justice and CMS officials. We also 

interviewed Department of Health and Human Services Office for Civil 

Rights officials about the applicability of the Health Insurance Portability 

and Accountability Act of 1996 Privacy Rule to the notification of facilities 

about residents who are sex offenders or parolees. 

To determine whether states we reviewed have laws or long-term care 

facilities have practices that provide for notification of these individuals 

and to determine the extent to which these individuals are subject to 

supervision and separation requirements that differ from those for other 

residents, we reviewed laws and interviewed state officials responsible for 

long-term care facility licensing, industry officials, long-term care 

ombudsmen, and the administrators at 29 long-term care facilities, which 

were chosen based on the criteria discussed above. We also interviewed 

Department of Corrections’ officials regarding their efforts to inform 

facilities about their placement of parolees in them. To determine what 

information on sex offenders is available to the public, we also reviewed 

state sex offender Web site registries available in the states we reviewed.

The key sources used to identify registered sex offenders and parolees 

living in long-term care facilities included CMS’s OSCAR database, the 

NSOR, and parolee databases from selected states. To assess the reliability 

of these data, we conducted electronic data testing, reviewed relevant

documentation, and interviewed knowledgeable agency officials about the 

data quality control procedures. We determined that while the NSOR does 

not include all registered or convicted sex offenders, its records are 

regularly audited and are sufficiently reliable for the purposes of this 

report. The lack of comprehensiveness of the data was evaluated and 

taken into account in our discussion of the results. The OSCAR database 

and state parolee databases were also found to be sufficiently reliable for 

our purposes. 

We conducted our work from September 2004 through February 2006 in 

accordance with generally accepted government auditing standards. 

Page 33 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix II: Registered Sex Offenders Living 

in Nursing Homes and ICFs-MR

To determine the prevalence of registered sex offenders residing in longterm care facilities nationwide, we matched the addresses of registered 

sex offenders listed in the NSOR as of January 3, 2005, with the addresses 

of nursing homes and ICFs-MR listed in CMS’s OSCAR database. Using this 

methodology we identified 683 registered sex offenders living in long-term 

care facilities. The number of registered sex offenders identified as 

residing in long-term care facilities in each state varied considerably, 

ranging from 0 to 144, as demonstrated in table 4. 

Table 4: Registered Sex Offenders Identified as Living in Nursing Homes and ICFsMR, by State, 2005 

State Nursing homes ICFs-MR Total

Alabama 1 0 1

Alaska 3 0 3

Arizona 15 0 15

Arkansas 10 1 11

California 141 3 144

Colorado 9 6 15

Connecticut 9 2 11

Delaware 6 0 6

District of Columbia 0 0 0

Florida 31 4 35

Georgia 14 0 14

Hawaii 0 0 0

Idaho 5 7 12

Illinois 78 2 80

Indiana 3 1 4

Iowa 9 5 14

Kansas 9 1 10

Kentucky 5 0 5

Louisiana 11 2 13

Maine 3 0 3

Maryland 2 0 2

Massachusetts 0 0 0

Michigan 18 1 19

Minnesota 22 3 25

Mississippi 0 0 0

Missouri 19 2 21

Appendix II: Registered Sex Offenders Living 

in Nursing Homes and ICFs-MR 

Page 34 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix II: Registered Sex Offenders Living 

in Nursing Homes and ICFs-MR

State Nursing homes ICFs-MR Total

Montana 1 0 1

Nebraska 0 0 0

Nevada 0 0 0

New Hampshire 4 0 4

New Jersey 12 0 12

New Mexico 13 2 15

New York 10 23 33

North Carolina 10 0 10

North Dakota 0 0 0

Ohio 3 0 3

Oklahoma 10 1 11

Oregon 6 0 6

Pennsylvania 0 0 0

Rhode Island 1 0 1

South Carolina 1 3 4

South Dakota 11 0 11

Tennessee 1 0 1

Texas 61 8 69

Utah 0 0 0

Vermont 0 0 0

Virginia 7 2 9

Washington 8 0 8

West Virginia 1 0 1

Wisconsin 20 1 21

Wyoming 0 0 0

Total 603 80 683

Sources: GAO analysis of the FBI’s NSOR as of January 3, 2005; CMS’s OSCAR database, 2004. 

Page 35 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix III: Comments from the Appendix III: Comments from the Department of Justice 

Department of Justice 

Page 36 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix III: Comments from the 

Department of Justice 

Page 37 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix III: Comments from the 

Department of Justice 

Page 38 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix III: Comments from the 

Department of Justice 

Page 39 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix III: Comments from the 

Department of Justice 

Page 40 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix IV: Comments from the Department Appendix IV of Health and Human Services : Comments from the 

Department of Health and Human Services 

Page 41 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix IV: Comments from the Department 

of Health and Human Services 

Page 42 GAO-06-326 Offenders in Long-Term Care Facilities
Appendix V: 

St

GAO Contact and 

aff Acknowledgments

Page 43 GAO-06-326 

Appendix V: GAO Contact and Staff 

Acknowledgments 

Kathryn G. Allen, (202) 512-7118 or allenk@gao.gov

In addition to the contact named above, Susan T. Anthony, Assistant 

Director; George Bogart; Katherine Crumley; Michaela M. Monaghan;

Elizabeth T. Morrison; Sari B. Shuman; and Kara Sokol made key 

contributions to this report. 

 Offenders in Long-Term Care Facilities

GAO Contact 

Acknowledgments 

(290416) 
GAO’s Mission The Government Accountability Office, the audit, evaluation and 

investigative arm of Congress, exists to support Congress in meeting its 

constitutional responsibilities and to help improve the performance and 

accountability of the federal government for the American people. GAO 

examines the use of public funds; evaluates federal programs and policies; 

and provides analyses, recommendations, and other assistance to help

Congress make informed oversight, policy, and funding decisions. GAO’s 

commitment to good government is reflected in its core values of 

accountability, integrity, and reliability. 

The fastest and easiest way to obtain copies of GAO documents at no cost

is through GAO’s Web site (www.gao.gov). Each weekday, GAO posts 

newly released reports, testimony, and correspondence on its Web site. To

have GAO e-mail you a list of newly posted products every afternoon, go 

to www.gao.gov and select “Subscribe to Updates.” 

The first copy of each printed report is free. Additional copies are $2 each. 

A check or money order should be made out to the Superintendent of 

Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 

more copies mailed to a single address are discounted 25 percent. Orders 

should be sent to: 

U.S. Government Accountability Office 

441 G Street NW, Room LM 

Washington, D.C. 20548 

To order by Phone: Voice: (202) 512-6000 

TDD: (202) 512-2537 

Fax: (202) 512-6061 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Gloria Jarmon, Managing Director, JarmonG@gao.gov (202) 512-4400 

U.S. Government Accountability Office, 441 G Street NW, Room 7125 

Washington, D.C. 20548 

Paul Anderson, Managing Director, AndersonP1@gao.gov (202) 512-4800

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, D.C. 20548 

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Mail or Phone 

To Report Fraud,

Waste, and Abuse in 

Federal Programs 

Congressional 

Relations 

Public Affairs 

PRINTED ON RECYCLED PAPER