Advocates Call for Substantial Funding Increases for Elder Care Reform

Elder Voice Family Advocates Report Reveals Inhumane and Deadly Neglect in Assisted Living Residences

MINNEAPOLIS--()--Elder Voice Family Advocates (Elder Voice) report on state investigations of neglect, abuse and exploitation reveals shocking deaths and suffering in many Minnesota assisted living and housing with services facilities.

Elder Voice Family Advocates, AARP Minnesota and Legal Aid call for strong new laws to protect older and vulnerable adults and substantial funding increases to license assisted living residences to provide quality elder and vulnerable adult care and safety. The current laws are weak and the Minnesota Senate leadership is grossly underfunding elder care with less than $5 million being allocated. This significantly lags behind the proposed budget of $31 – 33 million from the Minnesota Governor and House of Representatives.

“It is absolutely stunning that too many of our state assisted living residences are giving such deplorable care for our frail and vulnerable adults and yet we have Senate leadership ignoring the suffering and death,” states Kristine Sundberg, president of Elder Voice Family Advocates. “Our legislators have sole power to put Minnesota on the right path to end this inhumane and deadly neglect. Minnesota is the only state that doesn’t license assisted living and we are significantly behind most other states in providing basic protections from arbitrary discharge, retaliation, appeal rights and much more.”

Elder Voice examined investigation reports for Minnesota Department of Health’s, Office of Health Facility Complaints (OHFC) from August 2011 through November 13, 2018. Only substantiated investigations were reviewed, although the unsubstantiated and inconclusive categories are important and deserve future examination.

“We appreciate Representative Jennifer Schultz, Senator Karin Housley, Senator Scott Dibble, and many other legislators for their leadership in pursuing legislation to end this epidemic of neglect, abuse and exploitation,” states Jean Peters, RN, CNP and vice president of Elder Voice Family Advocates. “But substantial increases in funding for the licensing and other protections must also accompany the legislative reforms or we simply have another unfunded mandate that won’t help our elders and vulnerable adults.”

The Elder Voice review of a sample of 128 OHFC substantiated neglect reports showed that assisted living and housing with services facilities were responsible for 79% of the neglect. The OHFC determined that only 12% were of the neglect was the responsibility of individual(s). The remaining 9% were found to be the responsibility of both facility provider and individual(s).

Examples of the Gross Neglect Resulting in Death and Suffering. The following are disturbing examples taken from the investigation reports for several assisted living residences:

  • A resident was ignored for 3 ½ hours after falling. The staff let him crawl on the floor in his own feces, while the staff member walked past the resident on the floor without acknowledgement, watched TV, read a magazine and left the area several times.
  • 24 of 42 chemotherapy medication doses were not given – the resident died.
  • A dementia resident did not get the prescribed wellness check, wandered from the facility and drowned in a pond three blocks away.
  • Kitchen staff were directed to provide care and give medications. The assisted living residence had a 1:26 ratio of staff to residents.
  • A resident suffered a brain hemorrhage after a fall but was left on the floor for 4 hours with only a blanket and pillow.
  • Heart pump was not plugged into external power source and the resident died.
  • Staff ignored a resident with a history of hernias for many hours. The resident was screaming ‘help me, help me’ before staff finally got help but it was too late – the resident died.

Urgent Need for Legislative Reform. We ask that our legislators be responsible and fulfill their duty to keep all citizens safe and well cared for, including the elders who are frail and often unable to advocate for themselves.

  • Enact Assisted Living Licensure to ensure quality care in a safe environment that:
    • Creates a single contract required for housing and services to reduce confusion and promote continuity of care
    • Establishes special requirements for Dementia Care facilities
    • Establishes MDH Regulatory Powers/Authority
    • Requires resident registered nurse assessments prior to moving in and when health condition changes
    • Requires MDH to enact rules establishing minimum standards of care and staffing
  • Establish clear resident protections, including:
    • Protections against arbitrary discharge/service terminations
    • Authorization of electronic monitoring to detect and deter abuse
    • Prohibitions against retaliation against residents, families and employees
    • Prohibitions against deceptive marketing
    • Private enforcement of key rights
    • Creation of an Assisted Living Resident Bill of Rights
  • Significantly increase funding for MDH and DHS. They have been deluged with complaints in the past few years, but they haven’t gotten budget increases sufficient to handle this dramatic increase in work load and better curtail the neglect, abuse and exploitation. Funding for the following programs are critically needed:
    • Significant increase in staff to license assisted living
    • Modernize MDH case management system to an electronic system
    • Coordinate civil and criminal investigations with improvement to the Minnesota Adult Abuse Reporting Center, improve the data management abuse reporting system so consumers can see performance of operators
    • Conduct more on-site investigations of operators
    • Increase the staffing levels at the Office of Ombudsman for Long-Term Care of MN to improve the ability to detect, investigate, and resolve resident and family member concerns regarding quality of care, safety, and allegations of maltreatment

Systemic Failings of Assisted Living. Our review of substantiated cases of neglect in assisted living and housing with services facilities reveals several key failings of the assisted living industry. These failings result in serious harm and contribute to many premature and painful deaths as well as avoidable hospitalizations. The key reasons for this preventable suffering and death include, in part, the following:

Assisted living is accepting many residents with a wide range of care needs, without the capability to deliver the care that they promise:

  • No clear, consistent standards of care to guide the industry in the care of residents.
  • No nurse assessment of care needs prior to moving in to the residence
  • Poor communications among staff, management and other providers

Severe staffing problems include:

  • Dangerously low staffing levels
  • Inadequate or no supervision of direct care staff
  • Medication errors and theft
  • Ignored or untreated emergencies or significant changes of condition
  • Falls as a result of staff being untrained to competently use equipment for safe transfers
  • Neglect of care given sometimes leaving residents for many hours without food, water, toileting care, etc. or poor care of wounds that lead to severe, painful and sometimes fatal infections
  • Sexual predators take advantage of elders and vulnerable residents
  • Fear of retaliation prevents many from reporting neglect and abuse or advocating for themselves or their loved one

Inferior memory care standards result in:

  • Unsafe environments that allow wandering outside the residence
  • Poor dementia care training results in avoidable incidents, such as resident-to-resident incidents, wandering and emotional outbursts
  • Inadequate staff supervision of direct care staff

Many Assisted Living Residences Are Investigated Numerous Times. There were 27 assisted living and housing with services residences who have had 10 or more investigations in the past two years (2017 and 2018). One operator had 32 investigations with 8 of them substantiated in that time period. Another facility had 22 investigations and 11 were substantiated.

There were another 25 facilities with over 5 substantiated cases and 6 had 10 or more substantiated cases. These subpar operators clearly have not remedied their care and safety procedures and continue to neglect, abuse and exploit the elders and vulnerable adults dependent on their care. The need for stronger regulatory oversight and penalties is clear.

About Elder Voice Family Advocates: Elder Voice Family Advocates is a Minnesota based non-profit organization of family members and residents who have experienced significant neglect, abuse and exploitation at senior living establishments throughout the state. Additionally, other members are concerned professionals with deep experience in gerontology, elder abuse legal issues and direct care staff. The mission is to significantly improve the quality of care for all elders and vulnerable adults dependent on the services of the long-term care industry. For more information go to You can also find us on:
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Kris Sundberg: 952-239-6394 or

Release Summary

Elder Voice Family Advocates Investigation Report Calls for Elder Abuse Reform


Kris Sundberg: 952-239-6394 or