State regulators knew about the dangers at Superior View Assisted Living, a small senior care home set amid dense birch trees in northern Minnesota.
An elderly male resident died there in 2015 after being left for days without food, water and vital medications, state records show. Another resident died a few weeks earlier after staff failed to call a doctor when his blood sugar level soared to dangerous levels.
Other residents were left stranded in their rooms, unable to summon the staff for help, because their rooms lacked working emergency call lights.
As the violations piled up, the Minnesota Department of Health could have revoked Superior View's license, or even called in criminal prosecutors. Instead, it allowed the center to stay open, endangering dozens of residents, according to state records and interviews with former employees.
"It was a daily horror show," said Jessica Petersen of Duluth, a former caregiver there.
The state finally shut down Superior View in August 2016, but only after a devastating fire swept through the home and called public attention to its problems.
Superior View's history highlights a deeper breakdown in the way Minnesota regulates the rapidly growing assisted-living industry.
A Star Tribune review of state records found that fewer than half of Minnesota's 1,300 licensed home- and assisted-living providers are receiving complete inspections, or "full surveys,'' on schedule — within the three-year period required by state law.
Some facilities have never been inspected, records show.
Josh Berg, a former high-ranking official with the Health Department, said one reason for this breakdown is the "wrist-slap" treatment of troubled facilities like Superior View, which allows violations to keep piling up.
State inspectors who oversee these facilities spend much of their time reviewing old violations and reissuing prior corrective orders, said Berg, who for two years directed the Health Department division that regulates assisted-living facilities. That leaves them far behind in inspecting other facilities.
"There is this assumption that, when you put your mother or your father in one of these facilities, that someone must be watching — but that's not always the case," Berg said.
Berg left the Health Department in 2015 to lead a nonprofit, Accessible Space Inc., that operates 19 assisted-living facilities across Minnesota. He said state inspectors have never conducted a full survey of his facilities.
In 2012, state inspectors cited Superior View for nearly a dozen violations, such as failure to update client medical records, inadequate staff training and using unqualified workers to perform medical procedures.
Three years later, regulators found that Superior View staff failed to call physicians in at least two cases when residents developed grave medical problems and then died.
“We had people passing away that no one even knew were dying.”
For some serious violations, such as failing to administer medications correctly, Superior View was fined as little as $100, records show.
"We had people passing away that no one even knew were dying," said Petersen, the former Superior View caregiver.
Robert Gannucci, the home's former owner, said he knows of many residents who were happy at Superior View. "If we were such a bad company, then why were we allowed to operate so long?" Gannucci said in an interview.
If not for a harrowing incident two years ago, former employees say, Superior View might still be operating.
One afternoon in October 2015, a fast-moving fire tore through one of the home's two buildings. Firefighters encountered a chaotic scene, as confused dementia patients tried to rush back into the burning building after being evacuated, former staff said. Heat from the flames was so intense that bedroom windows exploded into shards of flying glass.
"We were lucky there weren't any body bags that day," said Jamie Tuura, who was a supervisor at the facility.
Superior View failed to report the fire or the displaced residents to county or state health officials — another violation of state law — records show.
Gannucci said the fire attracted the attention of state regulators, with the result that they conducted aggressive follow-up visits.
"It was a witch hunt," he said.
Ten months later, the Health Department revoked Superior View's license, making it just the second time in the past five years that the state has shut down a home.
Some former residents and their relatives say they are still haunted by memories of the place.
Janice Hiller of Hermantown said she struggles with guilt over the treatment of her late husband and regrets not moving him out of Superior View.
She arrived for a visit on one occasion and discovered him alone and disheveled after lying for hours in his own urine and feces. On another visit, Hiller said she saw unlicensed staff distributing medications to residents, a violation of state law.
Wallace "Wally" Hiller died in August 2015 of complications from Alzheimer's disease and chronic lung disease, five months after moving into Superior View.
During a recent trip to his grave in Duluth, Janice Hiller brushed grass and leaves off his memorial plaque, whispered, "I love you," and then apologized for the pain and suffering he endured. "Much of what they did to Wally was criminal," she said.
Gerald Pollard, 72, said he is still trying to forget about the nine months he spent at Superior View in 2015. Pollard, who is diabetic and walks on prosthetic legs, said the facility sometimes ran out of insulin without explanation.
To manage his fluctuating blood-sugar levels, Pollard said, he would hike 3 miles to the nearest store to buy candy and chocolate.
Lacking a walker or a cane, Pollard used an old golf club to steady himself during the journey.
Today Pollard lives in a different assisted-living facility, in West Duluth. It's a cramped and uncomfortable place, he said, but even so, Pollard feels relieved to have "escaped" Superior View.
"I've never felt so alone and so in danger for my life," he said. "It's unthinkable, really, that no one is checking these places."