A Duluth nursing facility has been cited for neglect in the case of a resident who died after falling from a wheelchair.

Staff at Bayshore Residence and Rehabilitation Center, which is on Park Point, "failed to comprehensively assess a resident at a high risk for falls, and reassess the risks after each fall," Minnesota Department of Health special investigator Barbara White wrote in a report issued May 4.

White found that the patient had fallen 10 times between July 5 and Nov. 24 last year, including falls on Nov. 17, 22 and 24. After the final fall, the resident was found on his back a few feet away from the wheelchair with a cut on his head. Later, after he was found pale and unresponsive, he was taken to a hospital, where it was found that he had suffered bleeding on the brain. He was placed in hospice care and died on Nov. 28, the report stated.

The report noted that the facility had taken corrective action and was in compliance with health department requirements as of last month. However, it added, taking corrective action doesn't mean the facility had acknowledged neglect, and it has the right to appeal the finding.

Rob Karwath, a spokesman for Bayshore, said the nursing facility didn't plan to appeal. Bayshore followed proper procedures but failed to adequately document the steps it had taken, he said.

Nonetheless, the facility has implemented new preventive procedures since the end of January, Karwath said. That led to a one-third reduction in the number of falls over three months this year compared with the same time period last year, he said.

Bayshore is operated by New York-based Paragon Healthcare Group.