A resident’s death might have been avoided if an on-duty caregiver was not sleeping when a contributing injury occurred, an investigative report by the Minnesota Department of Health alleges.

The caregiver employed at Emerald Crest (now Cassia) was captured on video sleeping July 11 during her shift, when a resident fell and broke her femur. The resident had Alzheimer’s disease and a history of waking during the night. She later died from complications related to the injury. The caregiver subsequently was fired.

“This tragedy affected everyone at Emerald Crest, and we want to express our deepest sorrow that it happened at all,” a statement from the community said. “Our primary concern is for the resident’s family and for the residents we serve. Their safety and well-being is our highest priority.”

The community (now owned by Cassia) has been issued a correction order “regarding the vulnerable adult’s right to be free from maltreatment,” according to the report.