St. Vincent's Prospera: Morphine Reconciliation Failure - ND
Nobody had caught it.
That's what federal inspectors found during an April 2025 survey of St. Vincent's - A Prospera Community, a nursing home at 1021 N. 26th Street in Bismarck. The facility failed to reconcile a discrepancy in its controlled medication records for a resident who had been prescribed morphine sulfate concentrate for pain, and the gap between what the paperwork said and what was actually in the bottle went unresolved.
The resident at the center of the finding, identified in inspection records as Resident 68, had a physician's order for morphine sulfate concentrate at 20 milligrams per milliliter, prescribed at 0.25 milliliters four times daily for pain, with an additional 0.25 milliliters available every hour as needed. Morphine sulfate concentrate at that strength is a Schedule II controlled substance, meaning it carries the highest recognized potential for abuse among drugs that have accepted medical uses.
At 8:40 a.m. on April 2, a staff nurse opened the medication cart and retrieved the bottle for Resident 68. It was empty. The narcotic count sheet attached to that bottle showed 4.25 milliliters of morphine sulfate still remaining.
The facility's own policy, updated just a month before the inspection, spelled out exactly what staff were supposed to do. The outgoing nurse was required to unlock the controlled medication storage unit, read each controlled substance aloud to the incoming nurse, and verify that the physical count in every bottle matched the number recorded in the narcotic count book. The incoming nurse was required to physically examine each container for signs of tampering. If the count didn't match, the error had to be resolved before the end of the shift, and the director of nursing had to be notified before anyone left the building.
None of that had happened with Resident 68's morphine.
An administrative nurse, identified in the report as Staff Nurse 2, told inspectors that afternoon that she expected staff to reconcile and report any discrepancies with narcotic medications immediately to nursing management, in line with facility policy. She did not explain why this particular discrepancy had gone unreported.
Inspectors noted that failing to reconcile and dispose of controlled medications creates the potential for medication errors and drug diversion. Drug diversion, in the context of a nursing home, means a staff member taking a controlled substance intended for a resident, either for personal use or to sell. It's a recognized problem in long-term care settings, and the shift-change count process exists specifically to detect it before it compounds.
The inspection report rated the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected. The finding applied to one of two residents whose medication passes were observed during the survey period.
What the report does not say is what happened to the missing morphine. The inspection does not document whether anyone was disciplined, whether the facility filed an incident report, or whether the discrepancy was ever explained. The administrative nurse's statement was the last word on the matter in the public record.
Resident 68 was prescribed morphine for pain. Whether they received the doses the records suggested were still in the bottle, or whether those doses were administered and simply not counted off correctly, or whether the medication left the facility some other way, the inspection report doesn't say. The count sheet said 4.25 milliliters. The bottle was empty. That gap, as of the date inspectors documented it, remained unresolved.
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.
That's what federal inspectors found during an April 2025 survey of 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.