Every year, hundreds of residents at senior care centers around the state are assaulted, raped or robbed in crimes that leave lasting trauma and pain for the victims and their families. Yet the vast majority of these crimes are never resolved, and the perpetrators never punished, because state regulators lack the staff and expertise to investigate them. And thousands of complaints are simply ignored.

State records examined by the Star Tribune show the scale of the failure.

Last year alone, the Minnesota Department of Health received 25,226 allegations of neglect, physical abuse, unexplained serious injuries, and thefts in state-licensed homes for the elderly.

Ninety-seven percent were never investigated.

That includes 2,025 allegations of physical or emotional abuse by staff, 4,100 reports of altercations between residents and 300 reported drug thefts.

When the Health Department did investigate, records show that it often neglected key steps in a criminal probe. In dozens of those cases, for instance, no one interviewed the victim and no one called the police.

Health Department documents contain dire tales of residents being choked, punched, smothered with pillows, fondled and forcibly restrained. At a nursing home in New Hope, an 85-year-old patient with dementia was repeatedly struck in the face and stomach over a span of months while other employees watched. At a care home in Crookston, an angry staff member lifted a female patient off her feet and threw her several feet to a bed, while calling her an "old hag." In Sartell, two nursing home employees witnessed a fellow worker sexually molesting a patient; they did nothing and the worker molested two more patients. And in Isanti County, an elderly woman with dementia was placed in solitary confinement for seven hours, in a frigid room with no lighting.

"We are putting up with a level of criminality in senior facilities that would be unthinkable in any other setting," said Amy Sweasy, an assistant Hennepin County attorney who handles elder abuse cases.

The state Health Department has broad authority to intervene in such cases. It can order corrective measures such as better training for staff, impose fines, or even revoke a facility's license and shut it down. The department is also required under state law to notify prosecuting authorities when it finds evidence of criminal abuse.

That system routinely breaks down, records show.

Investigations drag on for months. Fines go uncollected. Resident-on-resident abuse is often ignored, if reported at all. And prosecutors say they typically don't learn of state investigations until months after the abuse occurred, which makes criminal charges difficult, and at times impossible.

Families of victims are furious. They complain that the state will not tell them what investigators have discovered about their cases. Sometimes, they say, the state does not even notify them that an investigation is underway. Some families also have found that when they report their concerns directly to the facility's owner or other residents, their loved ones have been threatened with immediate eviction.

The result is that many of the 85,000 Minnesotans who live in state-licensed homes for seniors are denied equal access to the criminal justice system.

Source: Minn. Dept. of Health"It's painful to think about how many of these criminals are getting off the hook because we're sending these cases down an administrative black hole," said Nancy Fitzsimons, a professor at Minnesota State University, Mankato, who leads a state committee on abuse and neglect of vulnerable adults. "We, as a state, must recognize that these are crimes and they need to be treated as crimes."

Even executives in the senior care industry fault the Health Department for its ineffective response. They say facilities are deprived of vital information that would enable them to make essential fixes, such as firing abusive caregivers or increasing supervision.

Senior officials with the Health Department acknowledge that the state's inability to investigate most abuse allegations has far-reaching consequences for resident safety and care.

"The situation," said Gil Acevedo, assistant health commissioner, "is no longer tenable."

The volume of abuse allegations reflects rapid growth in Minnesota's elder care industry. The state now licenses nearly 1,800 residential senior care facilities, including hundreds of homes that provide specialized care for seniors with dementia. Minnesota spends more than $1 billion annually in Medicaid funds for senior care, in addition to tens of millions of dollars paid by families. Both figures are likely to climb as Minnesota's population ages.

The industry is also evolving in ways that are invisible to the public and difficult to regulate. More elderly Minnesotans are opting against traditional nursing homes and choosing to live their final years in less-institutional settings known as assisted-living facilities, which offer greater informality and independence.

The number of Minnesotans in assisted-living facilities has doubled over the past decade, to nearly 60,000, while the nursing home population has receded to less than 30,000.

Seniors in assisted-living centers are generally older, sicker and more volatile psychologically than in past years, making them more vulnerable to criminal abuse. But these facilities operate with much lighter state regulation than nursing homes. For instance, they are not required to maintain minimum staffing ratios, and they have fewer consumer protections, such as rules preventing arbitrary evictions.

These industry shifts have put Minnesota at risk of falling permanently behind the soaring number of abuse allegations, warned Iris Freeman, board member of the Minnesota Elder Justice Center and adjunct professor at the Mitchell Hamline School of Law.

"We should all be appalled by this picture," Freeman said. "Minnesota used to be at the top of the heap when it came to elder abuse enforcement, and now we're becoming known for being nonresponsive."

Robert Krause wakes up every morning to the memory of his dead mother.

Portraits of Jean Krause adorn nearly every wall and cabinet of his living room on the outskirts of Pequot Lakes in north central Minnesota. In many of the photos, Jean's long blonde hair is tucked beneath the nurse's cap that was part of her working uniform for most of her adult life.

One morning last summer, he received an unexpected phone call from a Crow Wing County assistant attorney, Janine LePage, who calmly informed Krause about "an important situation" involving his mother. Nearly a year had passed since her death. Krause suspected that LePage was calling about some minor dispute involving her estate.

He never expected to hear the words "sexual assault."

About 9 p.m. on May 8, 2016, Jean Krause was found curled up in a fetal position, naked below her waist, in her bed at the Heritage House assisted-living complex in Pequot Lakes, court records show. Just a few feet away, a male caregiver, David DeLong, who was 59, stood sweating and breathing heavily, with his jeans and underwear at his knees, according to an eyewitness account described in a criminal complaint. When a female aide spotted DeLong, he began awkwardly trying to pull up his pants and underwear, the witness recalled.

Supervisors at Heritage House waited nearly two hours after the assault before calling police, and only did so after sending DeLong home for the night, according to the police and a criminal complaint. Later, investigators discovered that two crucial pieces of evidence — Krause's red nightgown and mattress pad — had been placed in the facility's washing machine, possibly by DeLong, police and prosecutors say.

"It's infuriating," Pequot Lakes Police Chief Eric Klang said of the facility's handling of the case. "We had an eyewitness to a sexual assault of a frail woman with dementia, and the perpetrator was kept there and sent home without calling us. That's not proper protocol."

DeLong was never taken into custody by local police, and insisted on his innocence until detectives found DNA on the victim's body that matched his. Months later, even DeLong wondered why he was sent home on the night of the assault and not treated more like a criminal.

"Why didn't the people who saw me do it arrest me on the spot that night?" he asked, speaking from his home in Pine River, Minn.

After the police arrived, Jean Krause was sent to the hospital for a sexual assault exam. When she returned, Heritage House staff sent her back to the same room where just hours earlier she had been attacked, police and family members said.

In an interview with the Star Tribune, the owner of Heritage House said staff "acted properly" in sending DeLong home and then contacting police that night. She declined to discuss the family's complaint that no one contacted them about the sexual assault.

"We are just very thankful that it was caught and reported and is going through the judicial system, and people can feel that some justice is done," said Kathy Birchem, the facility owner.

LePage, the Crow Wing County prosecutor, said the facility's "blatant tampering" with the crime scene the night of the attack made it harder to prosecute DeLong. By cleaning up the victim and her bed, the facility compromised crucial physical evidence, making a serious charge difficult to prove, she said.

The failure to inform family of the assault was another setback, because relatives often play a major role in pressing for tougher sentences, she said.

eLong eventually pleaded guilty to one count of fourth-degree criminal sexual conduct, which involves force or coercion, in a negotiated deal that is common when prosecutors lack strong physical evidence. He agreed to a sentence of one year in jail and 10 years' probation.

In September, following Star Tribune inquiries into its regulatory history, Heritage House surrendered licenses for three of its properties under pressure from the state Health Department. It was just the second time in four years that a senior facility has surrendered its state license.

LePage said she sometimes wonders whether the outcome would have been different had the victim been a young girl instead of a 78-year-old woman who was unable to speak.

"If it was an 8-year-old girl, maybe someone would have rushed in and grabbed the girl, tried to protect her in some way," she said. "A protective instinct might kick in that didn't occur here."

Robert Krause said he never would have let his mother stay at the facility had he known about the assault.

"How do you live with yourself knowing that your mother suffered but you did nothing to help?" said Krause, sobbing.

The Health Department took four months to investigate the incident and then cleared Heritage House of any wrongdoing. State investigators reached that conclusion without interviewing Jean Krause or any of her family. The department's final report made no mention of the fact that Heritage House staff waited to report the crime, even though state and federal law requires the immediate reporting of maltreatment in state-licensed senior care facilities.

The state's failure to issue discipline in such incidents is the rule rather than the exception, according to records reviewed by the Star Tribune. Even when the state substantiates abuse, it frequently blames an individual employee, not a breakdown in the facility's management. The state has revoked the licenses of only two senior care homes in the past five years.

"Our current staff is really cracking under the pressure of our current caseload," said Deputy Health Commissioner Daniel Pollock, in testimony this spring before lawmakers, who approved a small increase in the agency's investigative budget.

Given the high volume of allegations filed each year, the department uses a triage system to sift through complaints and investigate the most serious cases first. Yet for two consecutive years, federal auditors from the Centers for Medicare and Medicaid Services (CMS) have cited Minnesota for incorrectly categorizing complaints as non-urgent, even when they involved severe abuse. The agency also failed to notify victims of their findings, the auditors said.

In recent audits obtained by the Star Tribune through public-records requests, CMS uncovered nearly two dozen allegations of serious harm and criminal abuse that were received but never investigated by the Health Department.

In one case, the state failed to respond to four separate reports of sexual abuse from a nursing home patient in Duluth. In another case, a nursing home resident had an unexplained black eye, a fractured foot and gangrene, but health officials categorized the complaint as nonserious. In another, a perpetrator confessed taking medications from patients in a nursing home, yet the state still categorized the complaint as not requiring an immediate investigation.

Minnesota's Department of Health has won accolades over the years for promoting public health and investigating disease outbreaks. But the agency has never put a high priority on fighting crime, advocacy groups for seniors say.

Source: Minn. Dept. of HealthOf the 27 Health Department staff who investigate abuse and neglect at state-licensed senior facilities, only one has a forensic background as a criminal investigator, agency officials said. The others are registered nurses with backgrounds as caregivers. The agency said it plans to hire three more investigators with forensic experience by year's end.

"We are overburdening a state agency that was never designed to investigate criminal behavior," said Suzanne Scheller, a Champlin attorney and founder of Elder Voice Family Advocates, a group of Minnesota families advocating for better care for seniors.

To assess the state's handling of serious allegations of abuse, the Star Tribune reviewed a sample of 300 investigations completed by the Health Department since 2014. They show that its inspectors failed to interview victims in roughly half the cases and failed to notify police in nearly 40 percent. Only a fraction of the cases ever reached a prosecutor's desk, according to county prosecutors interviewed by the Star Tribune.

In addition, completed investigations are removed from the agency's website every three years, making it difficult for families to assess a facility's safety record.

In 2011, concern over a surge in elder abuse allegations led Minnesota lawmakers to pass new criminal penalties, including prison time, for caregivers who intentionally neglect seniors under their care. Yet on average, fewer than 70 people are convicted each year under Minnesota's vulnerable adult statute — most of them for financial crimes, not physical abuse.

At the Star Tribune's request, a group of public prosecutors reviewed the 300 completed investigation reports. These attorneys, including prosecutors from Hennepin, Ramsey and Anoka counties, estimated that about one-third of the incidents had enough evidence of criminal wrongdoing to warrant charges or a formal criminal investigation.

"It's a huge area of concern that we're not seeing these [elder abuse] cases reach our desk, because the vulnerability of this population is huge," said Tara Patet, senior prosecutor in the St. Paul city attorney's office. "We have to treat elder abuse as the crime that it is, or otherwise it will keep happening."

Prosecutors also said the investigations included dozens of suspicious deaths that warranted forensic investigations but had not been treated as crimes.

In early 2015, for instance, nurses at a facility in Bloomington watched and did nothing as an elderly woman with neurological problems fell four times over three days, and eventually died of a catastrophic brain injury. Multiple nurses were aware of the patient's injuries, yet they never called her doctor, inspectors found.

In another case, in northern St. Louis County, a woman with Alzheimer's disease was found lying face down in a pool of blood outside her nursing home. The woman had unexplained facial fractures and died two days later in May 2016, state records show.

And early this year, a resident at an assisted-living facility in Maple Grove died from blunt force injuries five days after being found at the bottom of a stairwell, bleeding.

Prosecutors said that such suspicious incidents would probably be investigated as crimes if they occurred in a person's home or other community setting. But because they occurred in a state-licensed senior facility, they are routed through the Health Department, where nurses with little or no training in law enforcement review them as cases of medical neglect.

"Some of these cases would be a prosecutor's layup, but they never get to our desk," said Sweasy, the assistant Hennepin County district attorney.

She added, "If there was a 3-year-old child left standing in the middle of a busy intersection, we would all rush to hold someone accountable. But if an 80-year-old is physically or emotionally abused in a nursing home, then no one even knows what to do."

Officials with the Health Department say they are taking steps to respond more quickly to allegations of harm.

Over the past year, the agency has streamlined its system for receiving and processing complaints, eliminating unnecessary paperwork. As a result, it can now launch a formal investigation within days after receiving a report of abuse. Previously, it took the agency weeks or months just to assign a case to investigators. In the coming year, the department will begin discussions with city and county prosecutors on improving the flow of cases and evidence. Currently, the agency shares details of its investigations only when they are completed, which can be too late for prosecutors to file charges.

"We feel very strongly that every citizen out there deserves at least an acknowledgment that we're doing something, that we're on the case," said Acevedo, the deputy health commissioner. "When someone files a complaint with us … we owe it to the families to let them know that we take these allegations seriously."

Representatives of the senior care industry are urging the state to be more transparent about its investigations. Currently, the state collects data on categories of abuse, such as drug thefts and resident-to-resident altercations, but not on the types of facilities where they occur and who is targeted.

Industry representatives are also seeking more consistency in the handling of abuse allegations. Nursing homes, for instance, must submit written action plans to correct violations, while assisted-living and home care providers do not.

"Frankly, we have a great opportunity to address problems that have built up for decades," said Patti Cullen, president and chief executive of Care Providers of Minnesota, an association that represents the senior care industry. "If you keep throwing money at an agency that has systemic issues, then you're not getting at the root cause of why there are so many delays and problems that are not getting fixed."

E

rlier this year, a painful and mysterious affliction spread through Goldfinch Estates, a spacious seniors' complex that overlooks cornfields near Fairmont, Minn.

Longtime residents complained of nonstop pain, fatigue and loss of appetite. Normally outgoing men and women suddenly were bedridden, too weak to participate in the facility's many group activities, from bake sales to games of gin rummy. At least two residents were hospitalized.

Months passed before a pharmacist discovered the cause. A nurse's aide had been stealing full containers of painkillers from medication carts, then hiding the thefts by swapping them out with caffeine pills and other over-the-counter drugs. In the days following the discovery, more than a half-dozen residents came forward and complained of near-debilitating pain. They demanded an investigation.

The employee accused of taking the painkillers, Jennifer Ann Kiewiet, 28, was eventually charged with theft, drug possession and mistreatment of residents. She died of an apparent drug overdose just weeks before a scheduled court hearing, and the Martin County attorney's office closed the criminal investigation.

To the frustration of residents of Goldfinch Estates, that seemed to end the matter. At least three residents told the Star Tribune that they filed formal complaints with the Health Department. They hoped the state would uncover how Kiewiet was able to steal the medications for so long, and order Goldfinch to take steps to ensure it would not happen again.

While the agency launched a formal investigation, residents said they have not been interviewed since the thefts were uncovered nine months ago.

Meanwhile, Goldfinch Estates sent every resident a short form letter asserting that, to the facility's knowledge, "no resident" was "negatively harmed" by the incident.

"All I could do, night after night, was pray to God to let me die, and they try to claim that no one was even harmed?" said Delores Holz, 83, who estimates that she went three months without painkillers for her chronic arthritis. "It's like we're invisible."

El

ine Cottew, 90, said she found the letter "insulting." She waved it with anger as she described the agony of going without her pain medications.

"What do you mean, I wasn't harmed?" she said, her voice rising. "I was lying around like a zombie for weeks … Of course I was harmed. We all were."

Finally, last spring, about a dozen residents and family members gathered in the ornate lobby of Goldfinch Estates and demanded to speak with facility management about the drug thefts. An administrator declined to meet with the group, saying the issue was already handled, residents said.

"Residents just wanted some assurance that it wouldn't happen again, and they were just brushed aside like little children," said Gary Ricard, whose 91-year-old mother lives at the facility. "The arrogance really upset people."

Calvin Diekmann, executive director of Goldfinch Estates, said in an interview that the facility has taken steps to prevent another incident of residents receiving the wrong medications. Before pills are administered, he said, staff are now provided with a physical description of each drug to prevent mistakes.

Diekmann said he is still not aware of anyone who had been harmed by the drug thefts. "I've never gotten a doctor's report saying that" a resident was hurt, he said.

Even as the population of elderly Americans receiving long-term care has risen to more than 8 million nationally, state and federal budgets for combating elder abuse have declined slightly over the past five years.

Funding isn't the only challenge: A study by the National Institute of Justice found that the older the victim of sexual abuse, the less likely it is that the offender will actually be convicted. Investigators are also less likely to believe older people if there is no physical evidence of abuse, researchers found.

The surge in incidents of unchecked abuse has profound consequences for public health. A study published early this year by two University of Chicago sociologists found that elder maltreatment leads to significant declines in health, including greater anxiety, feelings of loneliness and increased susceptibility to disease.

Lori Smetanka, executive director of the Washington-based National Consumer Voice for Quality Long-Term Care, said awareness of elder abuse is still decades behind movements to stamp out domestic violence and child abuse. "We hear regularly from families across the country, that any complaint they file involving a [senior] facility goes down a black hole," she said. "Across the country, investigations are not happening in anywhere near the numbers that they should."

Ne

rly a year has passed since Marjory Aldrich's encounter with an abusive nurse.

Aldrich, 80, was recovering from pneumonia at a nursing home in New Hope and says she became frightened when the facility stopped giving her antibiotics.

She said she could feel fluid building up again in her lungs, and asked an aide about resuming her medications. When she got no response, she asked that a nurse call a doctor to renew her prescription. She said the nurse reacted by slamming a phone against her chest so hard that she nearly passed out.

"I laid there for 20 minutes, too petrified to move," she said.

A day later, Aldrich reported the incident to the Health Department, thinking someone would come to interview her.

No investigator came.

She called the agency three times to check on the status of her report.

No investigator returned her calls.

Last month, Aldrich received a letter from the Health Department informing her that the state's investigation into her case had been delayed until later this year.

From her mobile home west of the Twin Cities, Aldrich now wonders why she bothered to call the state agency instead of 911 or local police.

"This is why no one knows about these crimes," she said, holding up a copy of the state's last letter. "It's not because we don't have a voice. It's because people in power deliberately choose not to listen."

Chris.Serres@startribune.com 612-673-4308David.Joles@startribune.com 612-673-7904