Debbie Singer said her heart began to pound when she saw the newspapers piled against the door of her mother’s room at a senior home in Eagan.

When she opened the door, she was overwhelmed by the stench. She then noticed the body of her mother, 92, her legs dangling over the edge of her recliner. A stuffed kitten toy that Singer gave her mother was lying on the floor under her foot rest.

In a report issued this week, state investigators determined that Singer’s mother, June Alice Thompson, had died in her room last October, but her body was not found for two days because staff at her assisted-living facility — the Commons on Marice — failed to perform daily wellness checks as promised.

In their citation of the facility, the investigators also said it falsely documented that it had checked on Thompson.

“This is not how our loved ones deserve to be treated,” Singer said.

Commons on Marice said it reviewed its policies and procedures immediately after Thompson’s death and strengthened its process for “resident welfare checks.”

The recent failure underscores the vulnerability of residents in Minnesota’s nearly 1,200 assisted-living facilities, a fast-growing but lightly regulated segment of the senior care industry. They offer greater independence and less formality than traditional nursing homes, but have increasingly been admitting older people with more acute medical needs. Minnesota is among just a handful of states that do not license assisted-living facilities, which means that elderly, often frail, residents generally have no more protections than renters in ordinary apartment buildings.

The administration of Gov. Mark Dayton and a group of senior advocacy organizations are pushing legislation this year that would establish a licensing framework and create basic standards of care for assisted-living facilities, which provide housing and other services for nearly 60,000 Minnesotans.

Similar cases

Kristine Sundberg, president of Elder Voice Family Advocates, a coalition of family members of abuse victims, said the Thompson case is not unique.

In 2016, Sundberg’s father died in his room at a senior home north of the Twin Cities, and his body was not discovered for seven days, she said. Administrators had assured Sundberg and her family that they would make regular wellness checks if their father failed to show up for meals. However, the checks did not occur, and as in Thompson’s case, unread newspapers piled up outside his door.

Instead of offering condolences, Sundberg said, the facility’s manager told the family that they had to clean out his room by the end of the month, she said. “Allowing the assisted-living industry to continue to operate without being licensed will only result in more shocking incidents like what happened here and to my father,” Sundberg said.

David Salmon, executive director at the Commons on Marice, which has about 130 residents, said the facility has asked the Department of Health to reconsider its findings, in which the facility was held responsible for neglect.

“The care our residents receive is our top priority,” Salmon said. “As a senior living community, we sometimes have residents pass away while living with us, and our intent is to always handle those events with respect and sensitivity.”

Thompson moved into the Commons on Marice in 2013 and quickly made herself at home, Singer said. She became an ambassador to new residents and a board member; she sang in the facility’s choir, among other activities. Thompson was diagnosed with esophageal cancer in 2016 and required a feeding tube, but she remained independent enough to perform most daily activities independently.

‘Alert and cheerful’

On Oct. 24, 2017, Thompson met with family members and caregivers at the facility, where she appeared “alert and cheerful,” Singer said. Thompson said she looked forward to attending the facility’s Halloween party, and even had her walker festooned with a paper garland of pumpkins. She didn’t make it to the party that night, however. In fact, it was the last time that Thompson’s family members saw her alive.

Her body might have gone undetected even longer were it not for her attentive family. Singer said she rushed to check on her mother after her siblings became concerned that their mother was not returning telephone messages. “How long was she supposed to sit there before someone found her?” Singer asked.

When Thompson moved into the Commons on Marice, the facility had promised to provide “Daily I’m OK checks,” investigators found. According to a resident handbook, Thompson had a check-in button located on the wall in her bedroom. When she woke in the morning, she was to push the button to notify the front desk. If she did not push the button by 10 a.m., the front desk “will call to make sure that everything is all right,” according to the agreement.

‘Falsified record’

However, staff admitted to state investigators that they did not perform the checks as prescribed. A receptionist said there were times that not all the residents were checked on “because of other responsibilities.” State investigators reviewed the facility’s records and found that Commons on Marice had marked that it made a daily “I’m OK” check on Oct. 26 but concluded the record was falsified because the woman was not alive.

A review of the facility’s phone records also showed that no calls were made from the facility’s front desk to check on the woman in the two days after she was last seen by her relatives, investigators found.

The person at the front desk did not know what to do about Thompson’s body, leaving Singer to call for emergency help, she said. “The emotional stress and trauma I have experienced from this whole situation is difficult to describe,” she said. “I don’t want any other family to ever have to experience what we have gone through.”