State investigators are blaming inadequate staff training in the case of an elderly resident at a Sherburne County assisted-living facility who fell and suffered a fatal leg injury after getting out of her wheelchair.

Operators of the Big Lake residence owned by Cherrywood Advanced Living “failed to provide the necessary care and services to … train staff on the client’s use” of a high-back wheelchair that the woman was using when she stood and fell in March, according to an investigation by the Minnesota Department of Health.

Several nursing staff members told investigators that they were not trained on how to use the BRODA brand chair or “how to maintain the client’s safety when in the … chair.”

Cherrywood co-owner Wendy Hulsebus, whose company has offices in Sauk Rapids and additional facilities in St. Cloud, Richmond and Andover, said Monday that she disputes the state’s conclusion of neglect. “If a person is determined to stand up,” Hulsebus said, “unfortunately, they’re going to stand up.”

Hulsebus said her company registered concerns about the findings but may decline to appeal, citing the “lengthy and costly process.”

According to investigators:

The client, suffering from dementia and dependent on staff for her daily needs, was in a common living area on March 7 and “left unsupervised in an upright position” in her wheelchair. She fell and suffered slight head injuries and a broken right thigh bone. As the pain increased that night, the woman received an X-ray and was taken to a hospital emergency room.

Doctors determined that the woman was not a candidate for surgery, and she returned to the facility. She soon died, with the death certificate citing complications from the thigh fracture.

Hulsebus said the BRODA brand of wheelchair is a ­necessary piece of equipment and “extremely common in the skilled nurse setting. … We’re trying to get whatever training that we can get” to meet the Health Department’s expectations.