Nursing home operators in Roseville are being blamed for the death of a resident whose head became trapped between the mattress and the bed's grab bar.

Langton Place, which is operated by Presbyterian Homes, "had no policy, procedure or system to ensure the proper sizing of mattresses, the fit of the grab bars [or the proper] space between the mattresses and the grab bar device to reduce the risk of entrapment," according to a state Health Department report released last week.

The resident suffocated and died on May 31, according to the Ramsey County medical examiner's office. The woman's injuries included fresh bruising on her neck, the autopsy found.

While the Health Department did not disclose the woman's name, her husband identified her as Delores Rowan, 73, of North St. Paul.

Michael Rowan said Wednesday that his wife's suffocation "wasn't the only problem we had with that place."

Rowan said Langton Place one day ran out of the liquid nutrition she was fed through a tube. He also said she came down with cellulitis, a bacterial skin infection, and needed to be hospitalized. He said he also found caked feces in his wife's pubic area.

Asked for reaction to the husband's allegations, Roseville-based Presbyterian Homes spokeswoman Cindy Ray said in a written statement that "to maintain and respect the privacy of all residents and their families, we do not disclose or comment on health conditions or care procedures of any person under our care."

In response to Rowan's death, the state recommended a fine and "a plan of correction" in which nursing home administrators would outline how they intend to prevent a similar incident.

However, another official with Presbyterian Homes said Tuesday that the company is appealing the findings.

Natalie Morland, director of clinical services for Presbyterian Homes, said the size of the allowable gap between the woman's mattress and her grab bar "were well within [federal] guidelines" of 4½ inches.

A statement issued later Tuesday by Ray added that "we continue to examine such unexpected incidents fully so we can better learn how to identify, eliminate and avoid any similar risks.

"However, we do not agree with the state's findings and believe their responses have not taken into account all of the facts. We continue to work with the state and other experts to gain a clear understanding of the circumstances surrounding this death."

The report said a nurse saw the resident on her back and asleep about 4 a.m. In a routine check 90 minutes later, the woman was discovered with her head wedged between the mattress and a grab bar. Resuscitation efforts failed.

Nursing home administrator Mathew Bedard told an investigator that the facility had no policy for maintaining mattresses and grab bars or measuring for potential entrapment dangers, "but had maintenance staff fix things as issues came up," the report read.

Morland explained in an interview Tuesday that the state wasn't satisfied with the facility's maintenance policies and procedures, and wanted them in writing. She said Langton Place now "has a policy in writing" for mattress and grab bar maintenance.

Including Langton Place, the nonprofit Presbyterian Homes has 43 affiliated senior living communities in Wisconsin, Minnesota and Iowa.