According to the MDH, neglect was substantiated after the female resident, who lived in the facility's secured memory care unit, was able to find a supply of industrial-strength cleaning product and ingested it. The woman suffered chemical burns to her mouth and digestive system and died two days after the medical emergency. The woman's official cause of death was determined to be "complications of caustic agent ingestion."

A report compiled by the MDH states the woman's care plan included required safety checks every two hours.

During interviews with an MDH representative, staff indicated the woman "had a history of excessive eating." As a result, the nearest cupboards and refrigerator were locked. However, staff members reported the cabinet containing the cleaning product the resident ingested was not locked.

At the time of the incident, the report states a resident assistant said the woman "went into the kitchen like she always does" to get a glass of water. The resident assistant said she did not see the woman remove the cleaning product from a cabinet nor did she see the woman ingest the product. It was only when the woman went to sink to rinse out her mouth that the resident assistant reported realizing what had happened.

The MDH report indicates facility staff "assessed and organized" the six cupboards and drawers at the center and a schedule of cupboard safety checks was devised.

More from KSTP.com:

MDH finds nurse neglect led to resident's death at Northfield facility

Report says Hill City care center resident was beaten by staff member weeks before death

MDH: Farmington nursing home resident who fell getting out of bed was neglected