St. Vincent's Prospera: Dignity Violations in Commons - ND
Inspectors documented both incidents during a visit to St. Vincent's, A Prospera Community, a nursing home at 1021 N. 26th Street in Bismarck. The inspection, completed April 3, 2025, found the facility had failed to protect the dignity of two residents who received insulin injections and blood glucose checks in a commons area where they could be observed by anyone present.
The first incident happened April 1 at 11:43 a.m. Nurse #20 performed a blood glucose check on Resident #6, then pulled up the resident's shirt and administered insulin into the abdomen. Multiple residents and staff were watching. The next morning, April 2 at 8:25 a.m., the same nurse performed the same procedure on Resident #16 in the same setting. Again, multiple residents and staff observed.
Nobody pulled a curtain. Nobody moved the resident to another room. Nobody stopped it.
The facility had a written policy on resident dignity, revised as recently as December 11, 2024, four months before the inspection. That policy stated the facility's purpose was to help staff respect residents' rights, protect their private space, and ensure privacy and confidentiality. An administrative nurse told inspectors on the afternoon of April 3 that she expected staff to take residents to a private area before performing blood glucose checks or administering insulin.
That expectation was not what happened in the commons on April 1 or April 2.
Inspectors noted the violations carried the potential to affect residents' psychosocial well-being. Having a shirt lifted and a needle administered into the abdomen in front of an audience of peers and coworkers is not a minor procedural lapse. It is the kind of exposure that strips a person of ordinary control over their own body in a setting where they already have little of it.
The deficiency was cited at a level of minimal harm or potential for actual harm, and affected two residents. The scope was listed as few.
What the inspection does not answer is how long this had been happening. The two incidents inspectors observed fell on consecutive mornings. Nurse #20 performed both procedures. Whether this was routine practice, whether other nurses had done the same, whether residents had ever said anything or been asked, the report does not say.
St. Vincent's is part of the Prospera Communities network. For information on the facility's plan to correct the deficiency, CMS directs inquiries to the nursing home or the state survey agency.
Resident #6 and Resident #16 had their insulin administered in front of a room full of people. The facility's own policy said that was wrong. The nurse who did it worked there. The administrators who wrote the policy worked there too.
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 28, 2026 · Our methodology
ST VINCENT'S - A PROSPERA COMMUNITY in BISMARCK, ND was cited for violations during a health inspection on April 3, 2025.
Inspectors documented both incidents during a visit to St.
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.