BISMARCK, ND - Federal inspectors found significant deficiencies at St Vincent's - A Prospera Community nursing home during an April inspection, documenting widespread staffing shortages that resulted in extended call light response times and compromised resident care across multiple areas of operation.
Extended Wait Times Place Residents at Risk
The inspection revealed a pattern of inadequate staffing that left residents waiting dangerous lengths of time for assistance with basic needs. Multiple residents reported waiting 30 minutes to over an hour for their call lights to be answered, creating serious health and safety risks.
During resident council meetings from November 2024 through March 2025, facility residents consistently voiced concerns about prolonged response times. One resident reported waiting an hour for bathroom assistance, stating "I can't hold it that long." Call light logs confirmed this resident's 59-minute wait time on March 30, 2025.
The situation became so severe that one resident called police for help after waiting too long for staff assistance at 3:30 a.m. In another documented case, a resident was left without access to their call light from 10:00 p.m. until 3:00 a.m. before staff responded to their calls for help.
Medication Management and Safety Failures
Inspectors discovered critical failures in controlled substance management when they observed a nurse handling an empty morphine sulfate bottle that records showed should have contained 4.25 milliliters of the medication. This type of discrepancy in narcotic tracking creates serious risks for medication errors and potential drug diversion.
Federal regulations require immediate reconciliation and reporting of all controlled substance discrepancies to prevent medication errors and ensure patient safety. When narcotic counts don't match documentation, it can indicate theft, waste, or administration errors - all of which pose direct risks to resident care.
Food Service Temperature Problems Affect Nutrition
The facility failed to serve food at appropriate temperatures across all three residential units, with test measurements showing chicken served at only 104.8 degrees Fahrenheit - well below the temperature needed to maintain food safety and palatability. Other items measured even lower, with pasta at 94 degrees and vegetables at 98 degrees.
Residents consistently reported receiving cold meals, particularly those served in their rooms. One resident specifically moved from room service to dining room meals because "when I get my food in my room it is ice cold." Another resident waited for staff to prepare fresh, warm toast because the pre-made toast was cold.
Serving food at inadequate temperatures poses multiple health risks. Cold food loses nutritional appeal, potentially leading to decreased food intake and malnutrition. Additionally, foods held at improper temperatures create food safety hazards that can result in foodborne illness, particularly dangerous for elderly residents with compromised immune systems.
Neglected Basic Care Needs
The staffing shortage directly impacted residents' basic hygiene and toileting needs. Inspectors observed a resident repeatedly requesting bathroom assistance over a 2.5-hour period, only to ultimately have an accident in their wheelchair when staff failed to respond appropriately. Documentation showed this resident hadn't been toileted for over three hours despite care plan requirements for checks every 2-3 hours.
This type of neglect violates basic dignity standards and creates health risks including urinary tract infections, skin breakdown, and increased fall risk as residents attempt to meet their own needs without assistance.
Kitchen Sanitation Creates Health Hazards
Food safety violations extended beyond temperature control to basic sanitation. Inspectors found thick accumulations of black dust and dirt on fans and surfaces in both walk-in coolers and freezers, along with oven handles covered in peeling duct tape that created non-cleanable surfaces.
These conditions violate FDA Food Code requirements that protect food from contamination. Accumulated dirt and non-cleanable surfaces can harbor dangerous bacteria and pathogens, creating serious foodborne illness risks for vulnerable nursing home residents.
Medical Context and Industry Standards
Long-term care facilities must maintain sufficient staffing ratios to ensure safe, dignified care. Industry standards typically require call light response times of 15 minutes or less, with emergency situations requiring immediate response. Extended wait times can result in medical complications, falls, incontinence-related infections, and psychological distress.
Proper medication management requires strict protocols for controlled substances, including immediate reconciliation of any discrepancies. These safeguards prevent medication errors that could cause serious harm or death, particularly with powerful pain medications like morphine.
Food service standards in healthcare settings require maintaining hot foods at minimum temperatures of 140 degrees Fahrenheit to prevent bacterial growth and ensure nutritional quality that supports healing and overall health.
Additional Issues Identified
The inspection also documented failures to post current daily staffing information as required by federal regulations, problems with quality assurance programs designed to identify and correct systemic issues, and inadequate oversight of care planning processes.
These violations indicate broader systemic problems with facility management and oversight that extend beyond individual incidents to patterns of non-compliance with federal care standards designed to protect nursing home residents' health, safety, and dignity.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St Vincent's - A Prospera Community from 2025-04-03 including all violations, facility responses, and corrective action plans.
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