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Inhumane and Deadly Neglect Revealed in State Assisted Living Residences

Driven by Insufficient Funding for Regulatory Standards of Care and Oversight

April 9, 2019

Funded by Stevens Square Foundation

In Honor of the Thousands Who Have Suffered and Prematurely Died at Assisted Living Residences Throughout Minnesota.

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

Elder Voice Family Advocates’ (Elder Voice) review of substantiated investigations reveals

shocking deaths and suffering that needs urgent solutions that only the Minnesota Legislature can remedy. We undertook this review of publicly available investigation data of the Minnesota Department of Health’s (MDH) Office of Health Facilities Complaints (OHFC). The intent was to get a clearer picture of what is happening in assisted living residences throughout Minnesota and why is it happening.

Elder Voice reviewed substantiated OHFC investigation reports in Housing with Services/Assisted Living Residences (HWS/ALR) and identified many systemic problems. Given the massive amount of data, we reviewed just two neglect investigation categories and several “sexual abuse and financial exploitation” cases dated August 31, 2013 to November 13, 2018.

Key Findings - Limited Regulatory Oversight Driving Dramatic Increase in Neglect in Minnesota Assisted Living

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 providers

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

  • Medication errors and theft

  • Ignored or untreated emergencies or changes of condition

  • 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


Elder Voice Overview Report on Neglect Investigations - FINAL2
Download PDF • 2.00MB


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