Sandstone Health Care: Family Not Told of Choking - MN
The January incident at Sandstone Health Care Center was the first of two choking episodes that federal inspectors found went unreported to family members, despite facility policy requiring notification when residents experience significant changes in condition.
R8 had moderate cognitive impairment from dementia and epilepsy, according to his annual assessment. He was on hospice care and required a mechanically altered diet due to swallowing difficulties.
On January 12 at 12:14 p.m., R8 started choking and coughing on meat during lunch, then vomited. Staff documented they would monitor for signs of aspiration. They did not document contacting his guardian.
Six weeks later, another episode occurred.
On February 26 at 12:52 p.m., R8 began coughing with food in his mouth during mealtime. His face turned red and he appeared to have difficulty chewing and swallowing. Staff attempted to listen to his lung sounds because it seemed he had aspirated food into his lungs, but R8 was making "bear growling" noises that made assessment difficult.
Staff called hospice. Again, they did not call his guardian.
Licensed practical nurse LPN-E was in the dining hall during the February incident. She told inspectors that choking and aspiration concerns should trigger calls to family members or guardians. She confirmed hospice was notified but acknowledged the guardian was not called.
"Anytime there was a change in condition such as change in vital signs, mental state, or breathing the family member/guardian should be notified," LPN-E said during her April interview with inspectors.
Other nursing staff confirmed the same protocol. Licensed practical nurse LPN-D stated staff should notify both hospice and guardians for breathing issues or choking incidents. Registered nurse RN-B said both family and hospice should be contacted for any condition change so they can participate in care planning decisions, including potential diet modifications or emergency room evaluation.
The director of nursing told inspectors that after a choking episode with possible aspiration, once the resident is stable, nurses should notify the provider, guardian or family member, and hospice if applicable.
R8's care plan specifically identified interventions to observe and report signs of swallowing problems, including "pocketing, choking, coughing and holding food in mouth." His provider had ordered a mechanical soft diet with thin liquids in March 2025.
Progress notes from March 2025 through March 2026 showed no aspiration concerns until the January choking incident. The facility's own policy, dated July 25, required nurses to notify residents' representatives when significant changes in physical, emotional or mental health occurred, or when medical treatment needed significant alteration.
Both choking episodes involved a resident whose care plan already flagged him as at risk for nutritional problems and swallowing difficulties. His guardian remained unaware of the incidents that could have prompted discussions about diet modifications, increased monitoring, or medical evaluation.
The facility received a citation for failing to notify family when residents experience condition changes, affecting one of one residents reviewed for this issue during the April inspection.
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 13, 2026 · Our methodology
SANDSTONE HEALTH CARE CENTER in SANDSTONE, MN was cited for violations during a health inspection on April 8, 2026.
R8 had moderate cognitive impairment from dementia and epilepsy, according to his annual assessment.
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.
Frequently Asked Questions
- What happened at SANDSTONE HEALTH CARE CENTER?
- R8 had moderate cognitive impairment from dementia and epilepsy, according to his annual assessment.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SANDSTONE, MN, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from SANDSTONE HEALTH CARE CENTER or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 245454.
- Has this facility had violations before?
- To check SANDSTONE HEALTH CARE CENTER's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.