Sandstone Health Care Center
SANDSTONE HEALTH CARE CENTER in SANDSTONE, MN — inspection on April 8, 2026.
Found 7 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
(injury/decline/room, etc.) that affect the resident.
interview and document review the facility failed to notify family/guardian when a resident had a
Include: R8's annual Minimum Data Set (MDS) dated [DATE] indicated R8 had moderate cognitive impairment.
Diagnoses included dementia and epilepsy.
The MDS indicated R8 was on a mechanically altered diet.R8's care plan undated, identified a potential for altered nutritional status due to hospice.
Interventions included a mechanically altered textured diet and to observe, document, and report and signs or symptoms of dysphagia like pocketing, choking, coughing and holding food in mouth.R8's provider orders dated 3/19/25, identified a mechanical soft textured solid food diet with thin liquids.Review of R8's progress notes from 3/19/25 to 3/27/26 were reviewed and indicated the following:From 3/19/25 to 1/11/16, there was no documentation of concerns related to aspiration.on 1/12/26 at 12:14 p.m., R8 was eating lunch and started choking/coughing on a piece of meat and then ended up vomiting.
Staff would monitor for signs and symptoms (S/S) of aspiration.
The notes lacked information the guardian was notified of the choking and change of condition.On 2/26/26 at 12:52 p.m., R8 started coughing with food in his mouth at the mealtime. R8's face became red and appeared to be having difficulty chewing and swallowing.
Attempted to listen to his lung sounds as it had sounded like R8 had aspirated, but R8 was making bear growling noise, which made it hard to listen.
Hospice was notified.
The documentation lacked information related to notifying the guardian of the change in condition.
During an interview on 4/8/26 at 10:46 a.m., licensed practical nurse (LPN)-E stated anytime there was a change in condition such as change in vital signs, mental state, or breathing the family member/guardian should be notified related to a change in condition of the resident. LPN-E stated choking on food and concerns related to aspiration were included on the list of items that would trigger a call to family member or guardian. LPN-E confirmed she was the staff member in the dining hall on 2/26/26 at 12:52 p.m., when R8 had the observed choking and concerns related to possible aspiration. LPN-E stated hospice was called but that the guardian was not called at that time.
During an interview on 4/8/26 at 12:10 p.m., LPN-D stated nursing staff should call and notify both the hospice team and the guardian when there is a change in condition such as breathing issues or aspiration/choking on food while eating.
During an interview on 4/8/26 at 12:54 p.m., registered nurse (RN)-B stated both family and hospice should be called when there is any kind of change of condition in the resident so they are aware of the situation and can be part of the care planning for the resident.
Conversations would occur related to change in diets and possibly the need to send to emergency room for evaluation.
During an interview on 4/8/26 at 2:43 p.m., the director of nursing stated when a resident had a choking episode and concerns with possible aspiration, after the resident is stable, the nurse should notify the provider, the guardian/family member, and hospice if the resident is on hospice.Facility policy Change in a Resident's Condition or Status dated 7/25, indicated when a change in resident condition occurred the nurse would notify the resident's provider on call and the resident's representative when there was a significant change in the resident's physical, emotional, or mental health or when there was a need to alter the resident's medical treatment significantly.
245454 04/08/2026
Sandstone Health Care Center 109 Court Avenue South Sandstone, MN 55072
During an interview on 4/8/26 at 7:41 a.m., NA-B stated she was caring for R3 today, she had just transferred R3 off the bed so she could take her walker and go to the bathroom. R3 would put her light on when she was done.
NA-B confirmed she would be responsible for documenting resident BMs.
During an interview on 4/8/26 at 9:05 a.m., licensed practical nurse (LPN)-C stated for residents who took themselves to the bathroom the aids or nurses would ask them each shift if they have had a BM and then document it.
LPN-C stated only the nurses could see how many days it had been since the last BM.During an interview on 4/8/26 at 1:30 p.m., RN-C, an assistant director of nursing (ADON) stated it was the responsibility of the overnight nurse to run the bowel report and then enter the orders for day shift.
RN-C stated their bowel protocol started on day two of no BM, and if a resident had gone five or six days without then she believed you would do the enema, but added the residents had the right to refuse as well.
The nurses are pretty good about updating the doctor if they are having constipation issues, she hasn't performed assessments as part of that protocol. It is noted in the care plan that she does also take herself to the bathroom. [NAME] doesn't see the provider was notified.
Would expect a prescription PRN to be used.
She is known to refuse some meds. RN-C stated there was always the risk of impaction or obstruction, leading to perforation or infection.
During an interview on 4/8/26 at 2:07 p.m., the director of nursing (DON) stated her expectation was if staff were using the bowel protocol, and things weren't working they should be reaching out to the provider to update them to see if they need further intervention and would expect them to do an assessment as they were going on without effectiveness.A review of Facility Standing Orders, undated, identified on day two of no BM to give prunes, prune juice or bananas, apples and pears (BAP). On day three, give milk of magnesia (MOM) or lactulose. On day four, give bisacodyl suppository followed by tap water enema if no results.
Dosages for the above are, MOM give 30 milliliters (mL) orally as needed daily with a warning not to give if the resident has end-stage renal disease or dialysis, give lactulose instead.
For lactulose, give 30 mL by mouth daily as needed.
For bisacodyl, give 10 milligrams (mg) suppository rectally daily as needed.
For tap water enema, give 500 mL rectally as needed daily.A policy regarding the facility's procedures for bowel management was requested but not received.
245454 04/08/2026
Sandstone Health Care Center 109 Court Avenue South Sandstone, MN 55072
ROM and/or mobility, unless a decline is for a medical reason.
interview and document review, the facility failed to perform a passive range of motion (PROM)
Minimum Data Set (MDS) dated [DATE] indicated R13 was cognitively intact.
Diagnoses included multiple sclerosis (MS) and paraplegia.
Section GG indicated R13 had impairment to one upper extremity and both lower extremities. R13's Care Plan undated, indicated a potential for injury related to impaired mobility from paraplegia and MS.
Interventions included complete PROM/stretching program once a shift (1 time in morning and 1 time in evening).
Copies of PROM program were available at the nurse station 3. R13's PROM documentation from 3/10/26 to 4/8/26 were reviewed and indicated the following:10 shifts were documented as no not performed.14 shifts were documented as not applicable.6 shifts had nothing documented.During an observation on 4/6/26 at 4:23 p.m., R13 was observed to have contractures to her right upper extremity and both of her lower extremities
During an interview on 4/06/26 at 4:23 p.m., R13 stated the staff were always forgetting to do here PROM to her right upper and both lower extremities There have been contractures to those three extremities for some time due to her MS.
During an interview on 4/7/26 at 6:18 p.m., nurse assistant (NA)-A stated the care plan told the staff which residents had PROM programs, when they had to be done, and how often. NA-A confirmed R13 was on a PROM program that needed to be done daily during the day shift and evening shift. R13 would refuse the PROM program sometimes.
All PROM program documentation was documented on the plan of care and either yes or refused. If the resident refused, the charge nurse needed to be notified.
There was no reason to ever document under no or not applicable.
During an interview on 4/8/26 at 2:43 p.m., the director of nursing (DON) stated an expectation the NA would perform the PROM program when it was scheduled. A yes or refused would be documented in the plan of care when completed. If the resident refused, then the NA should report that to the charge nurse.Facility policy Restorative Nursing Services last approved 1/14, indicated residents would receive restorative nursing care to help promote optimal safety and independence.
245454 04/08/2026
Sandstone Health Care Center 109 Court Avenue South Sandstone, MN 55072
During an observation on 4/7/26 at 12:32 p.m. R8 was observed in the dining hall eating lunch.
There were no staff with him to monitor and assist him to eat his meal.
During an interview on 4/8/26 at 9:38 a.m., NA-B stated R8 frequently coughed when he eats.
They get the nurse when it happens, but it does seem like they are not changing anything to stop it. NA-B stated the staff was not aware of a need to monitor and assist R8 with meals.
During an interview on 4/8/26 at 10:18 a.m., hospice RN-E stated if a resident had concerns about aspiration, then we would work with the facility to either have a dietician or speech therapy evaluate the resident for diet and aspiration concerns.
Hospice was aware R8 had an increased risk of aspiration and there were current concerns of aspiration when he ate. RN-E reviewed the notes from visits on 1/12/26 and 2/26/26 and confirmed they had been called to perform a visit due to concerns with aspiration and choking when he ate.
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.
During an interview on 4/8/26 at 10:46 a.m., licensed practical nurse (LPN)-E stated She started working with R8 when the choking occured on 2/26/26. I was not R8's primary care nurse and the primary care nurse was the one who communicated with the hospice team. I am not sure if there was a request for speech therapy eval.
During an interview on 4/8/26 at 12:28 p.m., RN-C stated 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. If the resident was on hospice then either hospice or the facility staff could obtain the order for speech therapy. RN-C reviewed R8's order history and stated there had never been an order for speech therapy to evaluate swallowing since arrival in the facility.
During 4/8/26 at 2:43 p.m., the director of nursing stated 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.
Facility aspiration precautions policy was not received.
245454 04/08/2026
Sandstone Health Care Center 109 Court Avenue South Sandstone, MN 55072
Summary Report dated 2/4/26, indicated an order for Jevity 1.2 vial gastric tube at 30 milliliters per hour.
During an observation on 4/7/26 at 1:17 p.m., R28 was observed in bed laying on her back with the HOB flat.
The TF was observed running at 30 milliliters per hour continuously.
During an interview on 4/7/26 at 1:20 p.m., nurse assistant (NA)-F confirmed R28 was lying flat in bed with the TF running continuously. NA-F stated R28 needed to have the HOB greater than 30 degrees to prevent aspiration, but R28 liked to play with the controls and always lowered her own HOB below the 30-degree mark on her own. NA-F then entered a different resident room without going into R28's room to attempt to raise the HOB greater than 30 degrees or report findings to the charge nurse.
During an interview on 4/7/26 at 3:37 p.m., licensed practical nurse (LPN)-D stated all residents with TF were to have the HOB elevated over 30 degrees to decrease the risk of aspiration of the TF. If staff saw the resident with the HOB below the 30-degree level, they should attempt to raise the HOB over 30 degrees and report it to the charge nurse so the resident could be educated.
During an interview on 4/7/26 at 3:53 p.m. the director of nursing (DON) stated an expectation was for the staff to attempt to raise the HOB over 30 degrees if the resident was found with the HOB to low. If the resident refused, then 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.
Facility policy Enteral Nutrition last approved on 1/26, indicated possible complications included aspiration and esophageal swelling.
The policy did not mention safety precautions to decrease the risk of complications.
245454 04/08/2026
Sandstone Health Care Center 109 Court Avenue South Sandstone, MN 55072
bathroom, c. diff and before/after eating. To prevent the spread infection.
cares anytime they change from dirty parts of the process to clean parts of the process.
245454 04/08/2026
Sandstone Health Care Center 109 Court Avenue South Sandstone, MN 55072
failed to ensure the facility antibiotic stewardship program was followed for antibiotic use for 1 of 1
dated [DATE], indicated R13 was cognitively intact. R13's diagnoses included multiple sclerosis, dysuria, obesity, diabetes mellitus type 2, paraplegia, and dementia. R13's care plan dated 3/18/26, identified R13 had urinary incontinence and an indwelling catheter.A nursing note dated 2/23/26 at 3:01 p.m., indicated a message was sent on portal to the provider with an update on R13's urinary color, vaginal discharge, and increasing confusion and agitation.R13's provider orders dated 2/23/26 at 7:00 p.m., included Macrobid 100 mg capsule Give 100 mg by mouth two times a day for Dysuria for 7 Days: Macrobid 100 mg by mouth two times a day for 7 days.
The medication was discontinued on 3/2/26.R13's progress note dated 2/23/26 at 9:57 p.m., identified that a message was sent on portal to update the provider that R13's symptoms included urinary odor, vaginal discharge, increasing confusion and agitation.R13's Urine Culture Result dated 3/2/26 at 4:06 a.m., identified susceptibility profile is consistent with a probable extended-spectrum beta-lactamases (ESBL), a multi-drug-resistant organism greater than 100,000 colony forming units per milliliter (ml).
The antimicrobial susceptibility identified the organism was resistant to cefuroxime. R13's medical record lacked evidence of any established criteria (such as McGreer) being used to determine the presence of infection before an antibiotic was initiated. R13's medical record lacked documentation that non-pharmaceutical interventions were initiated prior to requesting an order for antibiotics.During an interview on 4/8/26 at 10:25 a.m., the infection preventionist (IP) stated nurses needed to identify a minimum of three symptoms, such as fever, change in cognition, or urinary symptoms when suspecting a urinary tract infection (UTI). IP stated R13's medical record reported R13's symptoms were foul smelling urine, discharge, and increased confusion/agitation when staff called the provider on 2/23/26.
The IP stated they usually complete a tool such as McGreer's criteria and confirmed there was no documentation that this occurred prior to obtaining antibiotic orders for R13 on 2/23/26.
During an interview on 4/8/26 at 10:39 a.m., registered nurse (RN)-C stated the order for the antibiotic Macrobid was received 2/23/26, and they obtained R13's urine sample on 2/25/26, the same day they received the order for the urinalysis. RN-C stated they typically would obtain a urine specimen prior to starting an antibiotic but R13 had a history of refusals and had refused a urine sample.
During an interview on 4/8/26 at 3:55 p.m., the director of nursing (DON) stated when a UTI was suspected, they expected staff to monitor symptoms, assess, follow McGreer's criteria, initiate standing orders to start UTI-stat and increase fluids, and update the provider.
The DON expected nurses to question a provider ordering antibiotics prior to specimen collection, document the discussion, and report concerns to the DON or IP nurse.The facility policy Antibiotic Stewardship dated 4/2024, identified that inappropriate use of antibiotics affects individual residents and the overall community with the potential for opportunistic infections, drug interactions, and drug-resistant pathogens.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SANDSTONE, MN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SANDSTONE HEALTH CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.