The death of a man who was injured in a fall down an outside stairway at a Biwabik nursing facility occurred because of the facility's neglect, according to a state investigator.

Staff members at the New Journey Residence, 100 Vermillion Trail, found the man lying face down two or three steps up from the ground in sub-freezing weather, according to the report filed by special investigator Kathie Siemsen for the Minnesota Department of Health's Office of Health Facility Complaints. The resident died 15 days later with the death certificate listing a head injury from the fall as the immediate cause, according to the report.

The report was concluded on May 9 after an April 9 visit to the facility and posted by the health department on Tuesday. The report does not name the victim, nor does it say when the fall occurred.

"Neglect was substantiated," Siemsen wrote. "The facility was responsible for the maltreatment. The facility failed to implement safety precautions when the client had a history of exit-seeking. The client was able to get outside without staff knowledge. The client had a fall, was injured and died."

The facility has the right to appeal the state's finding. A call seeking comment from the administrator at the parent facility, New Journey Residence in Eveleth, was not returned in time to appear in this story.

Siemsen's report said the client was diagnosed with vascular dementia but was not in the facility's memory care unit, which is on the first floor. He also was suffering from the effects of a stroke and hypertension and was on blood thinner medication. He was at risk for wandering off because of confusion, and the staff checked on him every 30 minutes during the day and every hour at night. Moreover, a motion alarm in his room alerted staff when he was up and moving.

On the night in which the client fell, staff members had heard an alarm when the man got up to use the bathroom, according to the report, but no alarm was heard when he apparently got up and left out of a second-floor door. All three staff members on duty were on the first floor in the memory care unit when they spotted the client lying on the steps and saw blood and footprints on the ground. He was wearing a T-shirt and sweatpants.

The staff called 911 and wrapped the man in a blanket, the report stated. He was able to walk to the ambulance with assistance. At the hospital, the client's core temperature was 90 degrees, and he was found to have bleeding on the brain, hypothermia and a vertebrae fracture. He also had frostbite on his knees.

The doctor discussed the man's condition with his daughter, explaining that he had suffered a potentially life-ending injury, Siemsen's report continued. It was decided not to have him transferred to a trauma center but for him to receive comfort care at the hospital. He was transferred to a skilled nursing facility six days later and died nine days after that.

During interviews, unlicensed staff members said they had requested that an alarm and/or a stop sign be added on the second-floor door.

An alarm was placed on the door the day after the fall, Siemens reported.

New Journey Residence opened in September 2015, according to its website.