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: August 5, 2026 · Our methodology
CURA OF SANDSTONE 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.