Minnesota officials have blamed the operators of a 94-bed nursing home for the death of a resident who suffocated when her head was trapped between a mattress and a grab bar.

Langton Place “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 Star Tribune report on state Health Department findings released last week.

The unidentified resident suffocated and had bruises on her neck when she died May 31, according to the Ramsey County medical examiner’s office.

An investigation revealed a nurse saw the woman sleeping on her back about 4 a.m., but staff found her face down when they returned for a check 90 minutes later. They were unable to resuscitate her.

The state recommended a fine and a correction plan.

But an official with Roseville-based Presbyterian Homes, which operates the five-star rated Langton Place, said Tuesday it is appealing the ruling.

Presbyterian Homes spokeswoman Cindy Ray said in a statement to the Star Tribune that management continues “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.”