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Inhumane and Deadly Neglect Revealed in State Assisted Living Facilities

April 2019

Elder Voice Advocates’ (Elder Voice) review of substantiated investigations reveals shocking deaths and suffering that need urgent solutions that only the Minnesota Legislature can remedy. We undertook this review of publicly available investigations data from the Minnesota Department of Health’s (MDH) Office of Health Facilities Complaints (OHFC) to get a clearer picture of what is happening in assisted living facilities throughout Minnesota and why is it happening. Elder Voice reviewed OHFC Investigative Reports of maltreatment in Assisted Living Facilities and identified many systemic problems.


  • 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​

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