Maltreatment deaths of Minnesota seniors prompt push for change
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State lawmakers have proposed more regulations and transparency for assisted living and nursing homes as advocates raise red flags.
The Minnesota Star Tribune
APRIL 11, 2026 AT 12:00PM
Workers at Larry Thompson’s assisted living facility stood by as he suffocated to death last year, his body wedged between the dining room wall and his electric wheelchair.
The 13 minutes of inaction cost the 79-year-old Vietnam veteran his life. It cost Meadow Ridge Senior Living in Golden Valley a $5,000 fine.
“That’s all that they had to pay, was that fine — $5,000 for the ultimate loss of my family losing our father,” Thompson’s daughter, Adrienne Sloan, said of the fine for what state investigators deemed neglect.
Her father was one of more than 20 Minnesotans who died from neglect or abuse in long-term care facilities in 2025, according to a first-of-its-kind report by the organization Elder Voice Advocates. The report drew from Minnesota Department of Health records, including situations where providers failed to check on clients, medications were improperly administered or clients fell and had complications.
But the count of deaths from maltreatment is subjective. The department said a review of their records shows 10 deaths from substantiated maltreatment, and noted that a couple of the situations in the advocates’ report occurred in 2024. The agency doesn’t produce a similar report showing annual maltreatment deaths.
The advocates’ report raised concerns about the growth in for-profit businesses operating assisted living facilities, memory care, nursing homes, home care and hospice. All but two of the deaths the group tallied reportedly occurred in for-profit facilities, where they claim “cost-cutting leads to substandard care.”
The report also says:
The bulk of the maltreatment appears to be occurring in assisted living, particularly facilities with memory care, rather than nursing homes or home care.
Many facilities where people died previously had numerous state-substantiated cases of abuse, neglect and exploitation. One Duluth nursing home had 25 such cases.
Some assisted living providers had very low staffing levels, including one with a single staffer for 70 residents and another with one for 50.
Neglect and untreated wounds were the most common causes of death, while others involved medication errors, staffing problems, wandering and physical abuse.
“As alarming as this report is, I can only imagine what the true scope of this really is,” said Elder Voice Advocates Executive Director Kristine Sundberg, noting the health department investigates less than 15% of the complaints it gets, and many events are never reported.
She hopes the collective picture will prompt state officials to better protect seniors living in the state’s 2,422 assisted living facilities and 337 nursing homes.
Health department officials said they look forward to working with advocates to ensure vulnerable residents get the care they deserve. The agency said it dedicates thousands of hours a year to site visits at long-term care facilities. The department said staff members do a preliminary investigation of every complaint to see whether it meets criteria for follow-up, with some cases investigated by the health department and some referred to other agencies.
The Minnesota Department of Health “shares the goal of compassionate, competent care for all long-term care recipients and is committed to protecting the health and well-being of residents,” the agency said in a statement.
Some legislators have taken up the advocates’ cause, including pushing a bill to prevent the situation that led to Thompson’s death by having plans and staff prepared to respond in medical emergencies. Another sweeping measure would add staffing requirements and increase transparency and guardrails for for-profit entities — some backed by private equity — that handle care for a growing number of aging Minnesotans.
“The horrors that they’re creating in those settings is just untold,” said bill sponsor Sen. Scott Dibble, DFL-Minneapolis. “It’s abominable and despicable and totally unacceptable. And we have to get a handle on it."
Bills would add senior safeguards
Staff at Meadow Ridge argued about what to do after Thompson fell trying to get on his electric scooter and was trapped nearly upside down, struggling to breathe.
Meadow Ridge’s policies directed staff not to touch a resident after a fall, but instead call the nurse, or 911 if a nurse wasn’t on site, according to the state investigation. The executive director didn’t respond to requests for comment.
Proposed legislation would require assisted living facilities to have plans to immediately help someone in a medical emergency and have someone with emergency medical responder training on site around the clock.
When people put their family member in assisted living — often paying $7,000 to $15,000 a month — they expect “there, in fact, will be assistance,” bill sponsor Rep. Ginny Klevorn, DFL-Plymouth, said during a hearing at the Capitol. “They expect more than a 911 call and having their loved one laying on the floor while waiting for those responders.”
Klevorn’s bill was pared back from an initial proposal that would have increased fines for facilities when someone died or was seriously injured. The Department of Health fines providers $5,000 in such cases of neglect, but businesses can also face licensing sanctions, and an individual responsible for abuse or neglect of a vulnerable adult can be charged with a felony.
A lobbyist told legislators that care providers aren’t sure whether facilities will be able to meet the requirements and retain enough people with emergency medical responder training to always have such a responder on site.
The Long-Term Care Imperative, which represents senior care providers, stressed that providers care deeply about quality and resident safety.
“The tried and tested way to improve quality measures is through investment in workforce, training, and person-centered care — not through punitive approaches that create compliance burdens without addressing root causes," the organization said in a statement. “Policymaking should focus on supporting providers and strengthening care delivery, rather than increased mandates and relying on penalties as the primary driver of better outcomes.”
Another bill backed by Elder Voice Advocates would go even further, setting minimum staffing ratios for facilities and requiring that they have a nurse on site 24 hours a day, with some exceptions. The idea comes as Minnesota faces a nursing shortage.
That measure will likely run into roadblocks in the closely divided House, Dibble said. But it would build on a major step the state took five years ago, he said, when it started licensing assisted living facilities, which have fewer guidelines than nursing homes.
Dibble’s bill would also add disclosure requirements and regulations when for-profit entities acquire nursing homes and assisted living facilities. Companies would have to provide information about their corporate structure and ownership and evidence that they have the ability and track record to run the facility well.
They would be barred from stripping assets from a facility or any act that would “undermine the quality of, safety of, or access to care.” Businesses would also have to spend at least 75% of the public funds they get on direct care for residents.
Deaths from neglect continue
As lawmakers debate additional regulations, deaths tied to neglect continue to be reported at Twin Cities facilities.
The Department of Health regularly uploads complaint investigations to its website. A batch of reports April 7 included a death following state-substantiated neglect at Personal Care Senior Living, an assisted living facility offering dementia care in Andover. The business did not respond to requests for comment.
A resident there fell as he tried to go to the bathroom after an employee failed to provide scheduled bathroom help and supervision. The man was found on the floor near his bed and the worker put him back into bed without addressing his pain or reporting the fall.
The man ended up in the emergency room due to a hip fracture from the fall. He died a few days later.