Sandstone Health Care: Choking Resident Left Unmonitored - MN
The resident, identified as R8 in inspection records, experienced multiple documented episodes where he turned red and appeared to have difficulty chewing and swallowing. During one February incident, a nurse attempted to listen to his lung sounds after suspecting aspiration, but the resident was making "bear growling noise" that made assessment difficult.
Staff called hospice during that episode, but documentation failed to include notification of the resident's guardian about his deteriorating condition.
On April 7, an inspector observed R8 eating lunch alone in the dining hall at 12:32 p.m. No staff members were present to monitor or assist him with his meal.
Nursing assistant NA-B told inspectors the next day that R8 "frequently coughed when he eats." The aide said staff would get the nurse when choking occurred, "but it does seem like they are not changing anything to stop it."
The nursing assistant revealed that staff "was not aware of a need to monitor and assist R8 with meals."
Hospice nurse RN-E confirmed during an April 8 interview that the facility should have requested either a dietitian or speech therapy evaluation for residents with aspiration concerns. The hospice team was aware R8 had an increased choking risk and current aspiration concerns when eating.
RN-E reviewed visit notes from January 12 and February 26 and confirmed hospice had been called to perform visits specifically due to concerns about aspiration and choking during meals.
"There had been no conversation related to dietician consults or speech therapy consults to get an appropriate diet ordered for resident safety but there should have been," RN-E told inspectors.
Licensed practical nurse LPN-E, who began working with R8 after the February 26 choking incident, said she wasn't the resident's primary care nurse. The primary nurse handled communication with the hospice team, and LPN-E said she wasn't sure if speech therapy evaluation had been requested.
Registered nurse RN-C explained facility protocol to inspectors: "If there was a resident with concerns related to aspiration and choking then a speech eval should be obtained to make sure the appropriate diet is ordered to keep the resident safe from choking."
RN-C noted that either hospice or facility staff could obtain the speech therapy order. After reviewing R8's medical records, she confirmed "there had never been an order for speech therapy to evaluate swallowing since arrival in the facility."
The director of nursing reinforced this standard during her April 8 interview, stating that "anytime there was a concern of choking and aspiration, the expectation was the staff would obtain a speech therapy evaluation order for the resident safety."
Despite multiple documented choking episodes and clear facility policy requiring speech therapy evaluation for aspiration risks, no such assessment was ever ordered for R8.
The facility failed to provide inspectors with their aspiration precautions policy during the investigation.
The inspection found that some residents were affected by deficient practices related to monitoring and safety protocols for those at risk of choking and aspiration. The violations represented minimal harm or potential for actual harm to residents.
R8's case illustrates a breakdown in basic safety protocols. A vulnerable hospice patient with documented swallowing difficulties was left to navigate meals alone, without the dietary modifications or supervision that could have prevented repeated choking episodes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sandstone Health Care Center from 2026-04-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SANDSTONE HEALTH CARE CENTER in SANDSTONE, MN was cited for violations during a health inspection on April 8, 2026.
Staff called hospice during that episode, but documentation failed to include notification of the resident's guardian about his deteriorating condition.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.