A wrongful-death ruling at an assisted-living facility was overturned in a rare successful appeal

The details of the assisted-living resident’s death were jolting.

According to an investigator’s report in December, a man who had suffered a stroke, was paralyzed on his right side and “required assistance with transfers, meals, bathing” and walking because of unsteadiness was found dead in his room — after staff failed to check on him for four days.

Officials said maltreatment by the facility, Souriyathay Housing With Services in Brooklyn Park, contributed to the man’s death. They ordered the facility to pay a $5,000 fine.

There was one problem: There was no maltreatment, owner Phinsaykeo Souriyathay said. And she had the detailed records to prove it. In April, state officials responded to Souriyathay’s appeal and in a rare move they reclassified the case as “inconclusive.” The fine was rescinded.

“I think they only wanted to see what they thought they’d see,” she said in a recent interview about the original report.

In 2021, a sweeping new state law was put in place to add order and accountability to Minnesota’s fast-growing assisted-living landscape. But in a state where nearly 60,000 seniors live in assisted-living facilities, obtaining a clear picture of facility quality and resident safety can be elusive, senior and family advocates say.

The law required facilities to be licensed. And it set minimum levels of care and established a system of inspections. Over the past three years, Health Department officials have received 10,000 to 11,000 complaints of maltreatment per year. While nearly every complaint receives a preliminary investigation, only about 10% are fully investigated, according to data from the Minnesota Department of Health.

And while the state publicly releases each week resolved cases of alleged maltreatment — classified as substantiated, unsubstantiated or inconclusive — a tally is hard to find.

Appeals are even rarer.

In 2023, the Department of Health received 41 requests to reconsider findings of maltreatment, said department spokesman Garry Bowman. In 2024, it was 90. So far in 2025, 32 appeals have been requested.

Fewer than 10% of those findings were changed, he said.

While Bowman said he couldn’t say what factors led to the state changing its determination regarding Souriyathay, analysts in the Reconsideration Unit serve as an “objective decisionmaker on appeals.”

During the reconsideration process, the unit reviews all documents, investigative records and medical reports, he said. Once the analyst’s assessment is complete, it is presented to a supervisor to review and approve. If approved, any public reports are modified if needed, Bowman said in an email.

In general, the process is “fair and objective,” said Amanda Johnson, chief operating officer of Care Providers of Minnesota, which represents 1,200 skilled nursing and assisted-living facilities statewide.

While thousands of complaints are filed each year, she said, “just looking at the volume of complaints can be misleading.”

Often, complaints are the result of misunderstandings. Other times, providers have already worked to correct problems, she said.

“I think the system has been created to [have people] be heard,” Johnson said. “It’s set up to allow providers and individuals to state their case.”

She acknowledged the system has few options for families to appeal when investigators say maltreatment is unsubstantiated or inconclusive.

The numbers appear to bear that out.

In 2023, Bowman said, there were seven requests to reconsider a determination of unsubstantiated or inconclusive maltreatment. There were nine in 2024 and, so far in 2025, there have been 10.

Of the 16 requests submitted in 2023 and 2024, only one was changed. Data was not yet available for 2025, he said.

Kristine Sundberg’s father died in 2016 at an independent-living facility for seniors. Despite facility staff not looking in on her father for seven days, despite promises to check on him if he ever missed a meal, maltreatment was not found, she said.

“That’s what got me going on this issue,” said Sundberg, now executive director of Elder Voice Family Advocates, a Minnesota coalition of elders, adults with disabilities and their families.

Providers have the right to appeal state determinations in court, Sundberg said. Families can only request reconsideration.

She admitted she was surprised to hear so few facility appeals result in changed determinations.

“That caught me off guard,” she said. “I thought it would be worse.”

Souriyathay began girding for a fight the moment she learned the state was blaming her facility for the resident’s death in August. She has a trove of records in her laptop.

From detailed care plans to forms signed by the resident to administer his own medication, her records refuted the investigator’s report on nearly every point, she said.

Souriyathay said she doesn’t understand how the state made the determination it did, but she’s glad it was changed. Still, she worries the mistake has tainted the reputation of the small facility she started five years ago to meet the needs of elders in the Laotian community.

The state didn’t know she kept supporting documents, including time-stamped logs showing the resident was not left alone for four days. Her paperwork also shows her staff didn’t give the resident medication because he had requested to manage it himself a month earlier.

“It’s in the note,” she said. “I kept everything.”