St. Vincent's Prospera: Blood Sugar Crisis Unreported - ND
The failure came to light during a federal inspection completed April 3, 2025, at the facility located at 1021 N 26th St in Bismarck. Inspectors reviewed the medical record of a single sampled resident, identified only as Resident #1, and found two separate instances in which staff measured dangerously elevated blood glucose levels and documented no attempt to contact the resident's physician.
The resident carried a diagnosis of type 2 diabetes. A physician's order on file since October 10, 2024, was direct: perform blood glucose checks before meals, and call the primary care provider if the reading fell below 60 or climbed above 400 milligrams per deciliter.
On January 24, 2025, at 12:22 in the afternoon, the reading was 567.
Two days later, on January 26, at 5:21 in the evening, it was 404.
Both numbers cleared the threshold the doctor had set. Neither one triggered a call. Inspectors reviewed the Blood Sugar Summary covering January 1 through March 31, 2025, and found no documentation that the facility had notified anyone.
A blood glucose level of 567 mg/dL is a medical emergency in most clinical contexts. The physician's order existed precisely to prevent staff from having to make that judgment call themselves. The number crossed 400. Call the doctor. That was the instruction. It did not happen.
When inspectors interviewed an administrative staff member on the afternoon of April 3, the response confirmed what the records already showed. Staff had failed to notify the physician of the high blood sugar readings on both dates. The administrator did not dispute it.
The inspection report cited a standard nursing reference, Kozier and Erb's Fundamentals of Nursing, for the underlying principle: when a physician's order is clear and not erroneous, the nurse is responsible for carrying it out. The order here was neither ambiguous nor complicated. It named a number. It named an action.
What the record does not contain is any explanation for why the calls were not made, whether anyone reviewed the readings before the survey, whether Resident #1 suffered any consequence from the two-day gap between the January 24 spike and any potential intervention, or whether the physician was ever notified at all before inspectors arrived.
The inspection classified the violation as causing minimal harm or potential for actual harm. That classification reflects the regulatory framework's assessment at the time of the survey. It does not describe what a blood glucose reading of 567 means inside a human body. Severe hyperglycemia at that level carries risks including diabetic ketoacidosis, a condition that can cause nausea, vomiting, confusion, and, without treatment, loss of consciousness.
St. Vincent's - A Prospera Community is a nursing facility operating under the Prospera Communities brand. The April inspection covered health standards and identified this deficiency as the basis for the statement of deficiencies. The plan of correction, if any, was directed to be obtained from the facility or the state survey agency.
Resident #1's physician set the threshold at 400 for a reason. On January 24, the number was 567. On January 26, it was 404. Both days passed. The doctor did not know.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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 failure came to light during a federal inspection completed April 3, 2025, at the facility located at 1021 N 26th St in Bismarck.
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.