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Inhumane and Deadly Neglect Revealed in State Assisted Living Residences



  • Legislative Reform of Assisted Living and Protections Must Pass in the 2019 Legislative Session

Key Findings

The horrific cases of neglect revealed in the substantiated investigations point to several key failings in the assisted living industry. These failings result in serious harm and contribute to many premature, painful deaths. The key reasons for all this suffering and death include, in part, the following.

  • Assisted living is accepting a wide range of care needs without credible authority and responsibility :

    • No clear, consistent standards of care to guide the industry, residents or families.

    • No nurse assessment of care needs prior to moving in to the residence

    • Poor communications among staff, management and other provider

  • Severe staffing issues include under-staffing, poor hiring practices, and training insufficiencies that result in:

    • Medication errors and theft o Ignored or untreated emergencies or changes of condition o Inadequate or lack of staff supervision

    • Falls as a result of staff being untrained to use equipment for safe transfers

    • Poor care given sometimes leaving residents for many hours without food, water, toileting care, etc. or poor care of wounds that lead to severe and sometimes fatal infections

    • Sexual predators take advantage of elders and vulnerable residents

  • Inferior memory care standards result in:

    • Unsafe facility environments that allow wandering outside the residence

    • Lack of adequate dementia care training leads to poor handling of common dementia related behaviors

    • Dementia residents lack appropriate activities to calm them


Consumer Protections and Rights


Licensure of Assisted Living

  • Two tiers of licensing – Assisted Living and Assisted Living with Memory Care

  • Establishes minimum standards of care, training and staffing

  • Rulemaking taking place 2019 – 2020

  • Effective August 1, 2021


Consumer Protections and Rights

  • Protections from: Arbitrary termination and retaliation.

  • Allows Elderly Waiver residents to continue living in the facility.

  • ‘I’m Ok’ checks must be clearly communicated.

  • Electronic monitoring clarified – effective 1/1/20.

  • Protection of elderly waiver residents.


Victims Fund Established

  • Compensates victims of maltreatment

  • Effective now and until 2021when Assisted Living Licensure becomes effective


Increased Funding for Regulatory Oversight

  • Supported significant funding increases for the Department of Health and 17 new staff for the Office of Ombudsman for Long Term Care

Licensure of Assisted Living


Minnesota was the only state that did not license assisted living facilities until licensure was passed in 2019:

  • Two tiers of licensing – assisted living and assisted living with memory care.

  • Establishes minimum standards for care, training, staffing and requires needs assessment prior to move-in.

  • Rulemaking is taking place 2019 – 2020.

  • Becomes effective August 1, 2021.

2019 Elder Voice Advocates 

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