At an assisted-living facility in Burnsville, an elderly resident was discovered dead in a pond after wandering away unsupervised. A resident of another facility died from a painful and untreated hernia after repeatedly crying out for help. At other facilities, residents fell in their rooms and were left on the floor for hours, unnoticed.

Those are some of the alarming cases cited in a 30-page report on Minnesota's assisted-living industry released at the State Capitol Tuesday by a coalition of consumer advocacy groups in support of legislation to improve safeguards for vulnerable adults. The report, compiled from state records, uncovered alarming conditions at some senior homes and numerous incidents of preventable deaths.

The assisted-living industry has mushroomed in recent years, admitting sicker residents with a wider range of disabilities. Yet Minnesota's consumer protections have not kept pace with these changes, exposing residents to serious harm and premature deaths, according to state records.

The consumer groups analyzed 128 substantiated cases of abuse and neglect since 2015 and found that nearly one-third of the incidents contributed to preventable deaths, while 55 percent resulted in avoidable hospitalizations and emergency room visits. The report also identified several problem operators with dozens of complaints, including one provider that has been the target of 32 state maltreatment investigations since 2015.

"It is absolutely stunning that too many of our state-assisted-living residences are giving such deplorable care for our elders and vulnerable adults," said Kristine Sundberg, president of Elder Voice Family Advocates, a grassroots group of relatives of abuse victims and the main author of the report.

This year, a coalition of senior advocacy groups — including Elder Voice, AARP Minnesota and Mid-Minnesota Legal Aid — has joined lawmakers and the state Department of Health in renewing a push for stronger protections for the more than 50,000 seniors who live in assisted-living facilities statewide. Legislation introduced this session would license assisted-living facilities for the first time and require them to maintain minimum standards of care and staffing levels, much the way Minnesota already regulates nursing homes.

Gayle Kvenvold, chief executive of LeadingAge Minnesota, a long-term care industry group, said "the time has come" for licensing the assisted-living industry and that her group supports the effort.

"We are serving a much different population today in assisted living than we did 20 years ago," Kvenvold said. "Still, it's a massive undertaking. We are overhauling the regulatory framework that we've had for decades."

Minnesota is the only state in the nation that does not license assisted-living services, and advocates say it has fallen behind many other states in establishing basic consumer protections for residents.

For instance, Minnesota is one of 17 states that lacks protections against arbitrary discharges from assisted-living facilities and one of 18 states that have no statutory protections against retaliation for seniors and others who report abuse, according to research by AARP Minnesota.

"Minnesota prides itself on being a leader in so many areas, but here we are an outlier," said Sen. Scott Dibble, DFL-Minneapolis, who introduced legislation this session expanding state oversight of senior care facilities.

The report issued Tuesday captures months of research and thousands of pages of state documents examined by Elder Voice volunteers and includes summaries of about 40 particularly egregious cases of maltreatment.

In a 2017 incident at Golden Nest assisted-living residence in Minneapolis, an elderly resident was left on the floor for four hours after a fall, without anyone contacting a nurse or emergency medical services. The resident was later diagnosed with a brain hemorrhage and died, according to a state investigation. The following year, a 76-year-old resident with dementia wandered away from the same facility on a winter afternoon and was found about eight hours later, lying in a snowbank. The resident had suffered severe hypothermia and later died at the hospital.

In many cases, the incidents reflected dangerously low staffing levels and inadequate training. One facility was so understaffed that it had kitchen staff responding to calls for personal care assistance at night, Elder Voice found. Another file showed that a resident of an assisted-living facility in Coon Rapids attempted suicide by consuming up to 85 doses of medications belonging to other residents, but no staff members were present in the building.

The untimely deaths chronicled resulted from a wide range of lapses, including failing to monitor and treat routine health problems such as diarrhea, dehydration and diabetes, the report found. Others died because wellness checks were not completed as prescribed and medications were not given or were given incorrectly.

The incidents highlighted in the report represent a fraction of the number of maltreatment complaints received by the Health Department's Office of Health Facility Complaints. The office currently receives about 400 allegations a week of abuse and neglect in nursing homes and other health facilities, according to state data. Between 2012 and 2017, allegations of maltreatment have increased 53 percent to slightly more than 24,000 statewide.

"Unfortunately, these are not one-time, rare events," Sundberg said. "There are dozens of facilities that are repeat offenders."