A fire that killed one resident and injured two others at a Woodbury assisted-living center last March is being blamed on a resident with a penchant for drinking heavily and smoking in his room.

State investigators issued their conclusion this week, and cited the facility's operators for negligence.

Officials at Woodbury Villa repeatedly admonished 77-year-old Russell W. Johnson — who perished in the fire — and threatened to evict him if he didn't quit smoking in his room, but never followed through, according to the state Department of Health.

The fire broke out about 4:15 a.m. on March 27 at the center, part of a senior living campus near Woodbury High School. More than 70 residents were moved to a nearby building at the complex as firefighters swarmed the scene. Two residents were hospitalized for smoke-related injuries and a firefighter was treated for smoke inhalation.

A Woodbury fire investigator confirmed that "careless cigarette smoking while on oxygen" by Johnson ignited the fire.

Woodbury Villa "failed to protect the safety of the clients," and its operators were "aware that [Johnson] continued to smoke cigarettes unsafely in the building and/or his apartment for approximately one year," the department concluded.

Woodbury Villa staff said they ramped up "safety checks" on Johnson late at night about two weeks before the fire and were looking for another place for him to live, the state report noted.

Jon Austin, a spokesman for Woodbury Villa, said Thursday that "while we respect the Department of Health's process and work closely with the agency, we disagree with their conclusion; it omits any recognition of the efforts we made to place this tenant in another setting. It is a point of sadness within our community that Mr. Johnson died before those efforts could come to fruition."

One of Johnson's two daughters, Renee Ashmore, said she has never been told anything by the facility's operators about the death of her father, who served 20 years in the Air Force in Thailand and Japan as jet mechanic, with much of that time during the Vietnam War era.

According to the Health Department investigation:

Johnson, an alcoholic, required continuous supplemental oxygen from a tank on the back of his wheelchair. Staff spotted him smoking as early as April 2014, despite a smoking ban throughout the building, and found overwhelming evidence that he was smoking, including cigarette burns on his sheets.

After about six warnings, Johnson was notified Dec. 31 that he would be given a 30-day notice to terminate the rental agreement if he violated the smoking ban. Two weeks later, he received a written "final warning," but he kept smoking, the report said.

In the hours leading up to the blaze, Johnson was in bed, "appeared intoxicated" and then quarreled with staff before eventually turning his oxygen supply from off to on.

About 45 minutes later, a nurse was alerted by a computer to smoke. The nurse ran to Johnson's room and saw his bed engulfed in flames.

Paul Walsh • 612-673-4482