Administrators of the Ramsey County Care Center in Maplewood are being blamed in the death of a resident who choked on her meal during a special Easter lunch March 31 and died the next day.

A care plan for the resident said she should be given food the consistency of pudding because she was toothless and had a history of choking, according to a state Health Department report released this week. Instead, she was served a special holiday tray with green bean casserole, ham, a roll, au gratin potatoes and lemon pie, the report said. The resident, who had a history of getting food caught in her throat, choked on a potato, developed asphyxiated pneumonia and sepsis, was taken by ambulance to a hospital and died April 1.

The error was traced by investigators to the resident’s tray ticket, which typically specifies dietary requests or needs. In this case, a holiday ticket was substituted for the regular one, investigators found.

Steve Fritzke, administrator of the county-operated nursing home, said Wednesday that “this was an honest mistake, with an unfortunate outcome.” The Easter menu was served as a “relaxed thing because people can have special things on the holidays,” he said. “There was a glitch. That has been corrected.”

Fritzke said the home has revised its meal procedures, retrained staff members and “took swift action” to prevent a similar incident at the home, which is licensed to care for 178 people.

Last year at the same facility, an aide was cited by state investigators for abusing a resident who had dementia. A 2012 Health Department report said the resident accused the aide of roughing him up in a shower and shoving him against a wall. The aide was fired and later pleaded guilty after being charged with misdemeanor assault.