MOUND, Minn. -The familyof a woman who died at a nursing home believes the death could have been prevented.

The Minnesota Department of Health's investigation into Luvern Kraft's death has citednegligence as a cause.Theinvestigation foundLuvern'scaretakerapparently wastoo tired to help the woman last April.

"She didn't deserve to go like that and she knew it was going to happen. She didn't want to go to Waconia," Luvern's son, Steve Kraft, said while holding back tears.

Kraft spent most of the past three years caring for his mother in their Mound home. But back in April, she was having more trouble than he could handle.

Steve said he took her to the hospital in Waconia. Within days, she was transferred next door to the Good Samaritan Society's Assisted living home.

"She had a pain in her back," Kraft said. "And she couldn't walk, I had to carry her into the bed."

At 86 Luvern's health was failing. Steve said she was legally blind, suffered from osteoporosis, needed oxygen to breathe and needed round the clock care. According to a Minnesota Department of Health investigation that care was compromised when Luvern became unconscious while going to the bathroom at Good Samaritan.

"Just hard to lose her," cried Kraft. "I can understand everybody's got to die, but you don't have to die because someone is too tired to dial the phone."

As part of the investigation, the Health Department determined Luvern's caregiver did nothing to prevent her death.

While that caregiver was trained and told to administer CPR as well as call 9-1-1, neither was done. The reason, according to the report, was that the caregiver was tired and not thinking clearly at the time.

A Good Samaritan Society spokesperson said as far as they were concerned all of their procedures and policies were in place and the fault lies with the individual. The state report concluded the same: the majority of evidence points to a caregiver that should have done more.

"She was a great person and she didn't deserve to have that happen to her, and I just don't want that to happen to anyone else," Kraft said.

The Department of Health's report has been passed on to the Carver County Sheriff's and Attorney's offices for possible criminal charges.

As for the employee, Good Samaritan told KARE 11, the caregiver quit immediately after the incident.

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