The call from the nursing home came at 5:30 a.m. on July 31: Your husband, admitted last night for a short rehab stay, has been found not breathing.

By 7 a.m. the woman and other family members had gathered at Crest View Lutheran Home in Columbia Heights when they heard the sirens. The fire department rescue squad entered her husband's room -- two hours after he died -- apparently called when the home's day-shift supervisor started work.

The incident, described in a state report released this week, sent state Health Department investigators to 122-bed Crest View, and has added fresh scrutiny to a facility already under special review because of past care infractions.

Not until the investigation was complete did the widow learn the extent of what the Health Department says went wrong that morning -- findings the home disputes.

The Health Department report gives this account:

The man, who is not identified in the document, was still warm, but not breathing and without a pulse, when the rehab unit manager found him.

The LPN and her nurse supervisor did not know that the man had orders for resuscitation, so they didn't try to revive him.

Even if they had known his "full code" status, the nurses did not know they were supposed to start CPR and call 911 even if no one witnessed his cardiac arrest -- a point of staff confusion affecting that resident and potentially 14 others with "full code" orders.

In addition, neither nurse had current CPR certification, neither had been briefed on emergency procedures and neither knew where to find the resuscitation kit -- found during the inspection, but missing several pieces of equipment.

"Something should have been done instead of calling me," the widow told investigators.

The home neglected the resident by not acting promptly to try to revive him, the department concluded, and was cited for three rule violations connected with the confusion, lack of action and lack of emergency training among key workers.

An inspection of the home on Oct. 26 found it had corrected the problems, the Health Department report said.

Minneapolis attorney Sam Orbovich, representing Crest View, said Friday that the home has appealed the finding of neglect to the state Health Department, and the three violations to the federal Center for Medicare and Medicaid Services.

The appeal said that the LPN was fired by the home, and that her comments to investigators were "erroneous and exaggerated." The nurse was properly trained and should have started CPR and called 911 "even though the resident was beyond resuscitation."

On problem-homes list

For the past nine months, the nonprofit Crest View has been one of four Minnesota nursing homes on a federal Special Focus Facilities list -- about 156 homes nationally with exceptionally troubling rule violations.

Crest View and other homes on the list are inspected every six months instead of yearly, and within 18 months they are expected to improve enough to be removed from the list. That happens when they complete two consecutive inspections without any of the most serious rule violations.

Crest View was placed on the list March 2. During three inspections since January 2008, the home was cited for 58 violations. (The state average is nine infractions per inspection). Complaint investigations added four more citations, including those from the incident in July.

Two of those were in the most-serious category, so it will take two good inspection cycles to get off the list, state officials said.

To read Health Department complaint findings, go to tinyurl.com/6e2usu. Warren Wolfe • 612-673-7253