A tiny burn on a nursing home resident’s foot, inflicted when she touched a heat register in her room while in bed, went neglected and triggered a rapid decline in her health until she died unnecessarily in an Iron Range hospital, according to state health investigators.

In the public portions of its findings released Friday, the Minnesota Department of Health blamed Heritage Manor in Chisholm for the woman’s death, determining that the home “failed to provide adequate supervision when the resident’s foot rested on a heater and was burned” in mid-February.

As is practice, the Health Department did not disclose the resident’s identity. However, the family confirmed that the woman who died March 1 was 91-year-old Mary C. Harris, of Hibbing, married for 66 years until her husband’s death and mother to two children.

Heritage Manor is operated by the nonprofit St. Francis Health Services of Morris. St. Francis has 15 senior care facilities throughout Minnesota, mostly in smaller communities.

The nursing home can appeal the findings, but St. Francis Vice President Scot Allen said “the fruitfulness of that are limited. The chances of winning are really low.”

Allen said the primary reason for Harris, who suffered from dementia, being burned in the first place was a family member urging staff to move her bed from the center of the room to a spot closer to a window, where she could enjoy the view and not be facing a closet.

“We’ve directed staff to [do] better assessments on residents who are not cognitively aware and keep them away from heat [sources],” Allen said Tuesday.

Harris’ doctor was kept in the dark about several obvious problems that snowballed soon after the initial burn and until shortly before her death, the state report noted.

“The resident’s primary physician … stated she did not receive notifications of the changes in the burn size and condition,” the report read. “Had the physician been notified, the physician would have observed the burn, made changes to the treatments and prescribed an antibiotic for the infection of the burn that developed.”

Instead, investigators said, the doctor was told of the burn only when it first occurred and measured less 1 inch square. What nursing home staff failed to tell the doctor was that the wound grew larger, was oozing, and turning red and then purple.

Then Harris lost her ability to speak, the bottom half of her body became covered with spots and irregular splotches, and her blood pressure fell, the report continued. While the family was told of the changes, Harris’ primary doctor remained uninformed. Additionally, a second burn near the first one went unreported to the doctor.

Harris went into septic shock and died four days after being admitted to Fairview Range Medical Center in Hibbing. Harris’ death certificate attributed her death to the infection setting in after the initial burn to her foot.

“Several staff had observed the resident’s bed in the position near the heat register, without identifying the potential hazard,” the state report read. “Several staff took care of the resident after [her] foot was burned and did not call the physician with the [changes] in condition.”

Harris was preceded in death by her husband, Minton, in 2012. She is survived by a brother, two children and two grandchildren.

“Mary took great satisfaction in writing cards to anyone facing challenges, struggles, sadness or illness to brighten their day and to let them know she was thinking of them,” read her funeral home obituary, which described her as a “homemaker by trade.”

“She cherished sharing her home and her excellent cooking with family and guests,” the obituary continued. “She cherished her family above everything, and she devoted her life to their care and happiness.”