Reversing a previous conclusion, state investigators are faulting management of the state veterans home in Minneapolis for the death of World War II veteran who fell from a mobility sling last year and broke his neck.

The Minnesota Department of Health said in findings released last week that the Minnesota Veterans Home-Minneapolis "failed to ensure staff members used the correct slings when transferring vulnerable adults using full body lifts." Previously, the state investigation labeled its findings "inconclusive."

During a transfer in July 2015, the man was moved with a shower sling, which "allowed a shifting of the weight" not found with a regular sling, the state noted. He fell out of the device and died 11 days later, the report said.

An earlier, inconclusive finding was reversed after a visit to the home by a representative of the maker of the lift used in the resident's transfer.

The representative found the lift to be in "good working order" and the sling, produced by a different company, in "good condition," the state report said.

A report issued by the manufacturer attributed the fall to "caregiver inattention and technique."

Although the Health Department, as is practice, did not disclose the name of the resident, an attorney for the family identified him as Frederick Switzer, 90, of Bloomington.

Attorney Joel Smith, who's representing the family in a lawsuit against the home's operators, said Monday that "the reason the [Health Department] reversed its earlier decision was due to the surviving spouse's persistence in challenging" the earlier determination.

Switzer was a mechanic for what was Northwest Airlines for 37 years after serving in the Army during World War II.

Investigators said they found at least two other instances that same summer in which staff used the wrong transfer sling. There was no mention of injuries associated with those errors.

In a statement, the veterans' agency said it could not discuss details of the case, but added: "The safety of our residents is the top priority at the Minnesota Veterans Homes. Over the last decade, the Minnesota Department of Veterans Affairs and our healthcare teams have put a tremendous amount of time, effort and resources into making the Minnesota Veterans Homes a place of honor for our nation's heroes."

State regulators recommended several "methods of correction," including monitoring staff to ensure that the lifts and slings are properly used, and that the home have the correct number of staff on hand for each resident transfer.

A follow-up inspection concluded that the home made the necessary corrections later that year.

The Minneapolis home, near the Mississippi River and Minnehaha Falls, is one of four operated by the Minnesota Department of Veterans Affairs. The others are in Fergus Falls, Hastings and Luverne.