Sandstone Health Care: Feeding Tube Aspiration Risk - MN
The April 7 incident at Sandstone Health Care Center involved a resident with moderate cognitive impairment and complete muscle loss on one side of her body who received more than half her nutrition through a feeding tube. Her care plan specifically warned of aspiration risk related to "inconsistent maintenance of head of bed greater than 30 degrees secondary to resident preference/refusal."
Federal inspectors found the resident lying flat on her back at 1:17 p.m. with her feeding tube running continuously at 30 milliliters per hour. The head of her bed was completely flat.
Three minutes later, nursing assistant NA-F confirmed to inspectors that the resident was lying flat with the feeding tube running. NA-F acknowledged the resident needed her head elevated above 30 degrees to prevent aspiration but explained the resident "liked to play with the controls and always lowered her own head of bed below the 30-degree mark on her own."
NA-F then entered a different resident's room.
The assistant made no attempt to raise the bed or report the dangerous situation to the charge nurse, despite facility protocols requiring both actions.
Licensed practical nurse LPN-D told inspectors all residents with feeding tubes "were to have the head of bed elevated over 30 degrees to decrease the risk of aspiration." When staff found a resident with the head of bed too low, "they should attempt to raise the head of bed over 30 degrees and report it to the charge nurse so the resident could be educated."
The facility's director of nursing confirmed staff expectations included attempting to raise the head of bed when found too low. If the resident refused, "the staff should report the refusal to the charge nurse so the charge nurse could educate the resident and if needed do a risk verses benefit."
The resident's care plan outlined specific interventions for her aspiration risk: ensure she was positioned with head elevated greater than 30 degrees during feedings, hold the tube feeding if she refused head elevation until safe positioning was achieved, educate her about aspiration risks, and inform the charge nurse of refusals.
None of these protocols were followed.
The resident's medical history complicated her care. Her annual assessment indicated she had hemiplegia, complete muscle loss affecting one side of her body, along with abdominal distention. She required continuous feeding through a gastric tube, receiving Jevity 1.2 at 30 milliliters per hour according to physician orders from February.
Her care plan identified a nutritional problem related to her hemiplegia diagnosis and called for tube feeding and water flushes as ordered. But the same care plan acknowledged her tendency to lower her own bed despite the aspiration danger this created.
The facility's enteral nutrition policy, last approved in January, listed aspiration and esophageal swelling as possible complications of tube feeding. However, inspectors noted the policy failed to mention safety precautions to decrease the risk of these complications.
Aspiration occurs when food, liquid, or stomach contents enter the lungs instead of the stomach, potentially causing pneumonia or choking. For residents receiving continuous feeding through tubes, maintaining proper head elevation is a basic safety measure to prevent stomach contents from flowing backward into the throat and lungs.
The resident's cognitive impairment meant she likely couldn't fully understand the medical necessity of keeping her head elevated, making staff intervention crucial for her safety. Her physical condition, with complete muscle loss on one side, may have made it difficult for her to maintain proper positioning without assistance.
Federal inspectors classified the violation as causing minimal harm with potential for actual harm. The finding affected one of one residents reviewed for tube feeding care during the April 8 inspection.
The incident highlighted gaps between written care protocols and actual practice at the 109 Court Avenue South facility, where staff knowledge of safety requirements didn't translate into protective action for a vulnerable resident who couldn't advocate for her own safety.
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.
with her feeding tube running continuously at 30 milliliters per hour.
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.