A resident at a Duluth senior care apartment complex who was known for rummaging around for food and something to drink downed a cleaning chemical that severely burned his digestive tract and killed him three days later, according to a state investigation.

The Health Department ruled that operators of Westwood of Duluth were negligent when the 70-year-old man inadvertently poisoned himself and died on Feb. 19.

The family on Wednesday identified the resident as Dale F. Nelson, who grew up on the North Shore in Grand Marais, joined the Navy and served in the Pacific during the Vietnam War, where he “received multiple awards for his service,” according to his online obituary.

The 34-year Enbridge mechanic, who is survived by three children and three grandchildren, “had a passion for his church, where he enjoyed ushering and singing worship songs,” the obituary noted.

According to details of the state death investigation released Tuesday, “The facility failed to implement safety precautions” knowing that Nelson “had a history of climbing over the kitchen gate [and] failed to otherwise secure chemical cleaners.”

This allowed Nelson, who was dealing with dementia and lived in a secured memory care unit, to drink “a caustic substance, which [caused] severe burns to the esophagus and stomach,” the report said.

In response to the death, Westwood staff removed chemicals from under the kitchen sink and put locks on all cabinets, the report said.

Westwood, one of two assisted living facilities in Duluth operated by the Benedictine Living Community, offers 35 small apartments.

Benedictine CEO Barb Wessberg said that facility management “evaluated and implemented additional safety and security measures to protect our residents. The Minnesota Department of Health has inspected the measures in place and determined that our policies and procedures are in compliance.”

According to the state investigation:

About 7:40 a.m. on Feb. 16, Nelson stepped over the gate while leaving the kitchen with liquid in a cup and handed it to an aide.

The aide immediately saw that Nelson looked ill. He was hospitalized and died three days later.

Nurses and other staff acknowledged in interviews with Health Department staff Nelson’s habit of scouring for food and beverages. Also, his care plan called for him to be checked on every two hours from 6 a.m. to 10 p.m. unless accompanied by a companion from a service.