St. Vincent's Prospera: Ativan Overuse, Care Failures - ND
The resident, identified in federal inspection records only as Resident #37, can walk with the help of one staff member and a front-wheeled walker. She has major depressive disorder and anxiety. Her own care plan noted what worked for her: she loves visiting with staff and enjoys listening to the TV.
Her care plan did not, however, specify what behaviors to watch for or what non-pharmacological steps to take before reaching for medication. That gap, inspectors found during an April 3, 2025 survey, contributed to actual harm.
Between December 18, 2024, and February 28, 2025, staff administered PRN Ativan — a sedative given on an as-needed basis — 50 times. The reasons documented in nursing notes included restlessness, agitation, rudeness to staff, refusing care, aggression, and wanting to leave the facility. None of those notes documented any attempt to first try talking with her, turning on the television, or any other non-drug approach.
The facility's own mood and behavior team met monthly. In January, a note recorded that her behaviors had been "much" — the sentence ended there, apparently incomplete — but added that no new concerns were noted. The February meeting produced a similar finding: no concerns with mood or behavior for the month. The March meeting noted she was "less anxious and wanting to sleep more."
That last detail is significant. Ativan is a benzodiazepine. Increased sleeping and decreased responsiveness are known effects. Inspectors wrote directly that the failure to try behavioral interventions before administering the drug may have contributed to exactly those outcomes in Resident #37.
A physician's progress note from March 4, 2025, acknowledged the pattern plainly. "Review of MAR does indicate PRN Ativan is used often," the note read. The physician's response was not to require non-drug interventions before the medication could be given. Instead, the doctor added a scheduled bedtime dose on top of the existing afternoon dose, while keeping the PRN order in place. The note described the resident as "overall improved and not so problematic."
The minimum data set assessments, completed at admission and quarterly, showed Resident #37 did not exhibit wandering, rejection of care, or verbal, physical, or other behaviors — the categories the facility tracks. Those assessments and the monthly behavior team notes painted a picture of a resident without significant behavioral concerns. The medication administration record told a different story: 50 doses of a sedative in less than two and a half months, sometimes twice in a single day.
The inspection cited the care plan's failure to address and specify her behaviors and the types of non-pharmacological interventions that should be attempted. The care plan knew she liked talking to staff. It knew she liked the TV. It simply never required anyone to try those things before administering a drug that makes people sleep.
Inspectors classified the violation as causing actual harm, affecting a small number of residents.
What the behavior team's notes described as improvement — less anxious, sleeping more — may have been something else entirely.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: October 29, 2026 · Our methodology
ST VINCENT'S - A PROSPERA COMMUNITY in BISMARCK, ND was cited for violations during a health inspection on April 3, 2025.
The resident, identified in federal inspection records only as Resident #37, can walk with the help of one staff member and a front-wheeled walker.
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.