After a Brooklyn Park assisted-living resident was found dead in his room in August, investigators with the state Department of Health recently concluded that the staff's negligence played a role in his death.

Then on Tuesday, the state Office of Health Facility Complaints reported the death of a resident of a St. Paul assisted-living facility who choked to death after staff failed to adequately prepare their food.

But Health Department officials last week said they couldn't provide one key piece of information: How often do residents of Minnesota nursing homes and assisted-living facilities die as a result of maltreatment?

The two deaths highlight the lack of statewide historical data for such deaths at adult care facilities.

While the state provides public details of its investigations of suspected maltreatment at facilities, summary data totaling those deaths would give a needed picture of the scope of neglect and abuse, said Kristine Sundberg, executive director of Elder Voice Advocates, a Minnesota coalition of elders, adults with disabilities and their families.

"By not letting the public know the astounding number of deaths happening in long-term care creates a dangerous false sense of security," Sundberg said. "This leads to more needless deaths and suffering."

It's a critical blind spot in ensuring adequate care for some of Minnesota's most vulnerable residents, said Cheryl Hennen, the state ombudsman for long-term care.

"This an issue that has come up before and there is a worry from a growing number of people," Hennen said. "How often are there substantiated maltreatment findings that resulted in death?"

For that reason, Elder Voice Advocates has developed a free tool, Elder Care IQ, to track such cases and so far has found 50 substantiated reports of neglect in Minnesota long-term care facilities in 2023 and 2024 — including 26 deaths.

"It's happening all the time," Sundberg said. "That's why we're working hard to get our analytics improved. Without transparency or accountability, how can we do anything about it?"

The lack of data has been noted as a problem in Minnesota for years. A 2018 review by the Office of the Legislative Auditor concluded that the state Department of Health's Office of Health Facility Complaints (OHFC) "does not collect some information needed to inform prevention efforts."

It went on: "In order to help prevent maltreatment from occurring, policy makers, MDH, providers, and other stakeholders need to understand the magnitude and nature of the problem. This requires collecting data that can be analyzed to determine how frequently maltreatment occurs, where it occurs, and whether there are trends associated with the number of provider staff on duty, the time of day, or other factors."

The report recommended the Legislature require the office to post all of its recent investigation reports on its website and to improve the search functions for investigation reports.

While the Health Department does not provide summary data of maltreatment deaths, spokesman Garry Bowman said in an email that the department's health regulation division has implemented several of the legislative auditor's recommendations since then.

Those include:

  • New electronic complaint, incident and records tracking systems.
  • The implementation of multiple quality control measures.
  • New assisted-living licensure laws passed by the Legislature in 2019 that went into effect on Aug. 1, 2021.

"The Health Regulation Division is constantly striving to improve processes and procedures to protect the health, wellbeing and safety of long-term care of residents and provide peace of mind to Minnesotans whose loved ones are cared for by the providers it regulates," Bowman said.

Maltreatment details

In an analysis completed last week of state investigation reports by Eilon Caspi, an elder mistreatment researcher and Elder Voice board member, the 26 deaths in Minnesota in long-term care facilities in 2023 and 2024 include:

  • A November 2024 report of a person with Huntington's disease who coughed blood for seven days before dying.
  • Two separate fatal resident-to-resident assaults in a dementia care unit of an assisted-living facility in May 2024.
  • A September 2023 report of a person with dementia in an assisted-living facility who died after spending 10 hours on the floor.

The report of maltreatment in August at Souriyathay Housing with Services in Brooklyn Park is jarring. According to the report by special investigator Michele Larson, who said she substantiated maltreatment, staff did not go into the man's room for several days — even though he hadn't responded to verbal requests or knocking on his door.

"Facility staff failed to physically check on the resident to ensure he was okay, or ensure the resident ate, took his prescribed medications, or received other scheduled services," according to a Dec. 31 state investigative report that determined the facility's maltreatment contributed to the man's death.

The man, who'd suffered a stroke, was paralyzed on his right side and had diabetes, chronic kidney disease and high blood pressure. He "required assistance with transfers, meals, bathing, and required supervision and stand-by assistance and a cane with walking due to unsteadiness." He also "was at risk for self-abuse and staff were directed to supervise the resident 24/7 for concerns of self-abuse and report concerns promptly to the nurse."

Yet, Larson wrote, he "was last physically seen alive, provided a meal, or administered his medications the sixth day of that month at 9:53 p.m., four days before first responders found the resident dead in his room."

The facility was fined $5,000.

However, the facility's owner, Phinsaykeo Souriyathay, disputed several of the report's details during interviews with the Minnesota Star Tribune last week, including that it wasn't four days between staff contact with the man and his death.

Staff members checked on the man several times and have the time-stamped progress notes, which were given to investigators, to prove it, she said.

Once, she said, "they could see him and hear him snoring."

She said his care plan also did not require staff to administer his medication. A few weeks before his death, she said, he'd taken that over. After he hadn't come out of his room, she said staff urged him to go to the emergency room. And he said, "I'm fine, I'm not in danger," she said.

Souriyathay said her facility is small, with just five residents. While it's open to all backgrounds and serves people from different ethnic groups, she opened it to meet a need in the area's Laotian community.

"I am here for the long run, because my community needs me," she said, adding that her staff speaks Laotian and the facility provides traditional Laotian food.

"I'm in this business because the community I am in, they're underserved," said Souriyathay, who also runs an adult day care program. "There has to be a deeper dive into exactly what is happening."