Case 1 - Death After Neglect

Agency Lack of Awareness of Provider Incident Report; Lengthy Process after Family Report; Threats to Continue Substandard Care; and Delayed Posting of Incident


After months of concern for the care being given a mother at a memory care facility and numerous care conferences with the provider, the family installed a video camera. Within three days of installing the video camera the family had clear evidence of multiple incidences of gross neglect and abuse including not being fed, given water, cleaned or moved for 16 - 18 hours in a stretch.


The family first reported the abuse and neglect to the Vice President of the organization by showing him the videos. The family was promised that the organization would report themselves to the Minnesota Department of Health (MDH). After two weeks of silence by the facility and MDH, the family, suspicious the facility self-report was never filed, submitted their own report and sent it certified mail to MDH. Following up with MDH two weeks later the family learned the report had never been reviewed or recorded as being received. The facility continued to ignore emails and phone calls from the family after the video camera documented further neglect of their mother's care which included daily cares and escorts to meals.


Their mother was placed on hospice after significant weight loss that was undetected and/or ignored by the caregivers and the facility. The family made the decision not to use the hospice associated with the facility and went to another hospice provider. Within days of hiring the other hospice provider, an email was received from the executive director threatening continuation of substandard care.


MDH substantiated the complaints filed by the family and the results were published to the Minnesota Department of Health website four months after their mothers' death and almost 7 months after the complaint was initially filed by the family. No documentation of the report, the facility stated they filed, was ever discovered.

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Case 3 - Sexual Assault in Memory Care Facility

Investigation Not Completed A mother with dementia was the victim of sexual assault by another resident at the facility where she had lived. This assault was witnessed by staff and reported to MDH.

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