A Cannon Falls nursing home is being blamed by state regulators in the case of a resident who died after choking on a sandwich despite strict orders that she should not be allowed to eat solid foods.

The Minnesota Department of Health, in findings released Wednesday, said the Gardens at Cannon Falls “did not have an adequate system to ensure cognitively impaired residents on [liquid] diets were adequately supervised.”

Nursing home staff knew the resident was dissatisfied with her limited diet and that she would routinely try to take the solid foods of others and throw her own meals onto the floor, the investigation noted.

The report did not disclose the woman’s name. State death records identify her as 77-year-old Margarita M. Schuler, who worked as a librarian for many years with the city of St. Paul until her retirement in the mid-1980s.

A nephew who lives a few miles from the nursing home expressed exasperation with his aunt’s care. “Wow, we had been working with the staff for quite a while about her needing extra care,” Mike Kulhanek said. “I was personally frustrated with that.”

Kulhanek said then-St. Paul Mayor George Latimer attended Schuler’s retirement ceremony and “commended her for her service” to the libraries.

He said his aunt felt especially close to him because she and her husband, who died in 1999, had no children. “She always took care of me and supported me emotionally,” particularly when he was attending college, he said.

The nursing home was ordered to correct its deficiencies in care and has the right to appeal the state’s findings. Speaking on behalf of the facility, a senior staff member declined to comment Wednesday.

According to the investigation:

On a Sunday night in mid-November, Schuler was in her wheelchair in the dining room and roughly 3 feet from where sandwiches, cookies and liquefied snacks were put out for residents.

When none of the three staff members in the room was looking, and after sitting near the snacks for more than an hour, Schuler rolled over to the food and “was trying to quickly eat the sandwich.”

When she began choking, staff members attempted to dislodge the food with chest compressions and the Heimlich maneuver, and called 911. Schuler died in an ambulance on the way to a hospital. Her choking caused her to go into cardiac and respiratory arrest, according to the death certificate.