BALTIMORE (Map, News) - It was 6 in the morning when a Rosewood employee went to wake one of the residents and found him blue and unresponsive.

She turned around, left the bedroom and walked back down a hallway, passing by a telephone on her way to find a nurse. It took another 10 minutes for the nurse to make her way back to the resident’s bedroom.

The findings are among many in a new state report charging the Rosewood Center with failing to respond immediately to an unresponsive resident, who was declared dead at 6:20 on the morning of Jan. 16, 2007.

The employee failed to administer CPR or immediately call 911, according to a recent report by the state’s Office of Health Care Quality, the agency charged with inspecting state-licensed residential facilities.

No one ever called 911, according to the report, the most recent in a string of disturbing investigations that ultimately led Gov. Martin O’Malley in January to order the Owings Mills center shuttered.

“While these results are not good, they are not nearly as severe as some of the past findings against the facility,” Wendy Kronmiller, director of the OHCQ, said of the most recent report.