St. Vincent's Prospera: Perineal Care Failures Found - ND
Inspectors documented the incident involving Resident 25 during an April 2025 survey of the facility at 1021 N 26th St. The resident was classified as experiencing minimal harm or potential for actual harm, and the finding affected a small number of residents.
The aide, identified in inspection records as CNA 3, confirmed during an interview on the morning of April 1 that staff are not supposed to wipe twice, meaning they are not supposed to use the same portion of the washcloth or repeat the motion in a way that recontaminates the area. The CNA confirmed this during an interview at 8:05 a.m.
Two days later, on the afternoon of April 3, two administrative staff members, identified as Administrative Staff 1 and Administrative Staff 2, both confirmed that the perineal care had not been completed correctly.
Administrative Staff 1 also confirmed that she expected staff to wear a gown when performing high-contact care for a resident under enhanced barrier precautions. The inspection record does not specify whether a gown was worn during the care provided to Resident 25, but the administrator's statement suggests that expectation was part of the standard she held for staff.
What the inspection record shows is straightforward: a basic hygiene task was performed incorrectly, in a way that everyone involved, the aide who did it and the administrators who oversee the unit, acknowledged was wrong. The CNA knew the correct technique. The administrators knew what they expected. And still, on the day inspectors observed care, it did not happen that way.
Perineal care performed in the wrong direction is not a minor procedural footnote. For residents who are incontinent, bedridden, or unable to clean themselves, the nursing aide performing that task is the only barrier between the resident's skin and the bacteria that cause urinary tract infections. Urinary tract infections in nursing home residents, particularly older adults with limited mobility or compromised immune systems, can escalate to sepsis. The direction of a single wipe matters.
The inspection report does not describe how long the incorrect technique had been in use, whether Resident 25 developed any infection following the incident, or how many other residents received care from the same aide or others using the same method. The finding was classified as affecting few residents, which under CMS definitions means the problem was not widespread across the facility, but that classification reflects scope, not severity of potential consequence for the individuals involved.
St. Vincent's is a skilled nursing facility operating in Bismarck, North Dakota, under the Prospera Community brand. The April 3, 2025 inspection was a standard health survey. The deficiency cited falls under the category of quality of care, specifically the requirement that residents receive care that maintains or improves their physical well-being.
The inspection record notes that for information on the facility's plan to correct the deficiency, the public should contact the nursing home or the state survey agency directly.
What the record does not answer is whether Resident 25, who needed help with the most basic and private aspects of bodily care, knew that the person helping them that day did it wrong, or whether anyone told them afterward.
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.
Inspectors documented the incident involving Resident 25 during an April 2025 survey of the facility at 1021 N 26th 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.