Operators of a St. Louis Park nursing home did little to keep a resident from repeatedly falling within a few months' time before an injury from a fall killed him, according to state Health Department investigators.

The Estates at St. Louis Park "did not comprehensively assess, determine causal factors or implement new interventions to prevent additional falls," according to details of the Health Department's investigation released this week.

The ongoing negligence occurred until the man's death on Jan. 13, the investigation found, despite the resident's care plan noting that he had a history of falling.

Talia Fletcher, the nursing home's administrator, said Thursday that her facility of 150 to 155 clients has "corrected the concerns … and the Health Department agrees with our corrective measures."

She added that the Estates at St. Louis Park now has "systems in place to aid residents in falls."

Those actions include assessing each resident upon admission of the risk of falling and, as warranted, analyzing each incident of a fall, and training all staff in that area of care.

According to the state's investigation:

The resident, who required assistance with his daily needs because of various ailments including "moderate cognitive impairment," was known to staff to be susceptible to falling and being unwilling to use his call light when having a difficulty.

He first fell on Oct. 19 and suffered a cut on his forehead. He was treated at a hospital and reminded to use his call light. No other actions were taken.

This pattern of response remained largely consistent as he fell three more times within a month, then again on Dec. 7 and Jan. 3. The falls often occurred as he moved himself between his bed and a wheelchair.

A particularly serious fall in November gave out a "big bang," according to one nurse, and left the resident with swelling on his forehead and complaining of pain from what turned out to be a broken hip.

Five days after falling on Jan. 3, the resident complained of abdominal pain, prompting him to be taken to a hospital emergency room for treatment for his broken hip and a urinary tract infection.

He died on Jan. 13 of complications from the fall and the resulting hip fracture. Investigators, as is their practice, did not disclose the resident's identity.

The Estates of St. Louis Park is operated by Mankato-based Monarch Healthcare Management Group, a company that has many facilities in the Twin Cities area along with other parts of Minnesota and Superior, Wis.