A ventilator leak at a Minnesota nursing home led to a resident’s death last year, causing the facility to become more aggressive in monitoring, a new report finds.

In the August incident, the ventilator for a resident had stopped working for 39 minutes before an employee of the Bethel Care Center in St. Paul, MN responded. The resident was found unresponsive and with a pulse, but later died, the Pioneer Press reported last week.

A review of data shows a “large leak or disconnection” of the ventilator system, according to newly released report from the Minnesota Department of Health. Staffers interviewed by the MDH said they were short-handed that evening because of staffing reductions on the ventilator unit.

The facility has since instituted a new staffing plan with an added associate to continuously monitor patient ventilator alarms. In a statement, Bethel Care Administrator Cory Glad noted that the facility follows protocols to ensure resident safety, and a November follow-up visit found Bethel to be in “substantial” conformity with state regulations. They’ve also developed a plan of correction and provided additional training for employees.

“Staff has taken aggressive measures to bring the facility into full compliance since the deficiencies were cited last year,” Glad said.