Sandstone Health Care: Range of Motion Neglect - MN
The resident, identified as R13 in inspection records, has paraplegia and contractures in her right arm and both legs from her progressive neurological condition. Her care plan specifically required passive range of motion exercises twice daily to prevent further deterioration.
Federal inspectors reviewed a month of therapy records from March 10 through April 8 and found a pattern of neglect. Staff documented 10 shifts as "not performed." Another 14 shifts were marked "not applicable" — a designation that should never be used according to facility policy. Six additional shifts had no documentation at all.
During the inspection, R13 told investigators that "staff were always forgetting to do her PROM to her right upper and both lower extremities." She explained that contractures in those three extremities had existed "for some time due to her MS."
The missed treatments have medical consequences. Multiple sclerosis causes progressive muscle weakness and spasticity. Without regular stretching, joints become permanently fixed in contracted positions, limiting mobility and causing pain.
A nursing assistant interviewed by inspectors confirmed the facility's requirements. The aide, identified as NA-A, said the care plan clearly indicated which residents needed range of motion programs, when they should be performed, and how often. For R13, exercises were required during both day and evening shifts.
NA-A acknowledged that R13 sometimes refused the treatments, but said staff should document refusals properly and notify the charge nurse. "There was no reason to ever document under no or not applicable," the aide told inspectors.
The director of nursing echoed this expectation during her interview. She said nursing assistants should perform range of motion exercises when scheduled and document either "yes" or "refused" on the care plan. If a resident refused treatment, staff should report it to the charge nurse immediately.
Yet the documentation tells a different story. Of the 30 shifts reviewed, only a handful showed completed treatments. The majority were either skipped entirely or incorrectly categorized as not applicable to the resident's condition.
R13's annual assessment, completed using the federally required Minimum Data Set, showed she was cognitively intact and fully capable of understanding her treatment needs. The assessment documented impairment to one upper extremity and both lower extremities, confirming the medical necessity of the prescribed exercises.
Her care plan, though undated, specifically identified a "potential for injury related to impaired mobility from paraplegia and MS." The prescribed intervention was clear: "complete PROM/stretching program once a shift (1 time in morning and 1 time in evening)."
Copies of the range of motion program were available at the nursing station, eliminating any excuse that staff couldn't access the requirements.
During their April 6 observation, inspectors noted visible contractures in R13's right upper extremity and both lower extremities. These fixed joint deformities represent the physical manifestation of the missed treatments.
The facility's own policy on restorative nursing services, last approved in January 2014, states that "residents would receive restorative nursing care to help promote optimal safety and independence."
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, but affecting few residents. The finding represents a failure to maintain or improve range of motion and mobility without medical justification.
For R13, the consequences extend beyond missed therapy sessions. Each skipped treatment potentially worsened her contractures, limiting her already compromised mobility and independence. In a condition like multiple sclerosis, where progression is inevitable, maintaining existing function becomes critical to quality of life.
The inspection occurred on April 8, revealing systematic neglect of a basic therapeutic intervention that could help preserve what mobility R13 has left.
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 neglect violations during a health inspection on April 8, 2026.
Her care plan specifically required passive range of motion exercises twice daily to prevent further deterioration.
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?
- Her care plan specifically required passive range of motion exercises twice daily to prevent further deterioration.
- 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.