For at least three years, a stairway door at an assisted-living center in Maple Grove wouldn’t lock without extra attention, according to a new state investigation. Repair orders went unfilled, even as signs on the door alerted staff to the malfunction and the problem was widely known among people at the facility.

Then, in January, 89-year-old Ula Peoples got behind the door in her wheelchair and fell to her death, and now state investigators have concluded that the operators of Wildflower Lodge are to blame.

According to findings from a state Health Department investigation released last week, the failure to fix the faulty door “contributed to a fall, and the client died five days after the fall due to blunt force injuries.”

The report went on to note that “direct care staff, maintenance staff, nurses and management were all aware that ... the door [was] not operating as intended, but no new interventions were put in place” to have it fixed.

Rather, the report read, signs were affixed to the door directing staff to “double check that door is locked before you walk away” and “wait for the click, 20-second delay for the lock to engage.”

An executive with the home’s owner, Dallas-based Capital Senior Living Corp., said he could not comment in detail while the case is under investigation, but added: “Our community is working diligently to examine all the facts related to this matter … The safety and well-being of our residents continues to be our primary focus.”

When Betty Lou Carlisle learned of the faulty door’s role in her sister’s death, “I thought it was terrible,” she said in an interview with the Star Tribune. “I understand it was reported and they hadn’t taken care of it. She had a pretty good life, and then to have it end that way.”

Sandra Kelly, Peoples’ daughter, said her family “has a lawyer engaged and investigating” the circumstances.

Carlisle said Peoples grew up in Michigan, attended college, married and raised two children in the Twin Cities while working in the cosmetics section of a department store.

At the time Peoples moved into Wildflower Lodge in late November, her medical file said she had dementia and was vulnerable to falls, the state report read. She also had opened and tried to exit through the door many times, the report added.

The state investigation into Peoples’ death on Jan. 24 also revealed:

On Jan. 19, staff found Peoples and her wheelchair tipped over on the landing of a stairwell late in the afternoon.

Notes were on the door at the time that directed staff to watch the faulty door and make sure it was closed and secured with its coded lock system.

“Maintenance had been notified about the door not locking unless it was reopened and shut,” the state report read.

The center’s service records show that maintenance orders were put in at least three times in the year before Peoples fell, including on the day of the incident.

Knowledge of the door’s problems were widespread at Wildflower Lodge, the investigation found. One staffer reported being aware of it needing to be fixed for more than three years and made “multiple verbal requests” to get the repair done. The staffer even demonstrated the malfunction to the maintenance director.

Another staff member said two other residents in the past three years got through the door, prompting nursing personnel to be notified.

One nurse said she gave “multiple verbal reports to the executive director” about the door malfunctioning. The executive director responded that she would look into it and acknowledged being told of the door’s difficulties at least three times within the past year.

The day after Peoples fell, the maintenance director “lowered the magnet plate to fix the problem.”

A relative of Peoples took photos of signs posted on the door, which read, “Stop, wait for the click, 20-second delay for the lock to engage,” and “Please double check that door is locked before you walk away. Door does not like to latch. Shut the door twice. Thank you, management.”

Wildflower Lodge is run by Dallas-based Capital Senior Living Corp., a for-profit business with roughly 120 facilities in 23 states with a combined capacity of more than 15,000 residents.