St. Vincent's Prospera: Care Plan Failures Flagged - ND
Inspectors flagged the gap during an April 3, 2025 survey of the nursing home at 1021 N. 26th Street. The resident, identified in inspection records as Resident 243, was described by staff as having an explosive temper and posing a serious threat to other residents. Staff said he put residents down and yelled obscenities at them or in front of them. He threatened them. He wandered the halls, knocking on doors and letting himself into rooms while searching for staff.
None of that was in his care plan.
A care plan is a nursing home's written blueprint for managing a resident's needs. It drives what staff do, when they do it, and how. When a resident is documented as a threat to others, a care plan is where the facility commits to a response. Resident 243's had no such commitment.
The same record that showed his behavioral history also showed a diagnosis of diabetes mellitus. His physician had ordered 100 units per milliliter of Insulin Lispro Injection Solution on a sliding scale, four times a day. Diabetes in a nursing home resident carries real stakes: blood sugar that swings too high or too low can cause confusion, falls, loss of consciousness, and organ damage. The care plan contained nothing about his diabetes, nothing about the symptoms to watch for, and nothing about what to do if complications arose.
Two failures for the same resident. One involving the safety of everyone around him. One involving his own.
Inspectors also reviewed the records of Resident 443, whose situation was different but whose care plan gap was just as concrete. Resident 443 had quadriplegia and an abdominal wound. A quarterly assessment had already flagged the resident as high risk for developing pressure ulcers, which are a known and serious danger for people who cannot move or reposition themselves. Pressure ulcers can progress from surface redness to deep tissue destruction, sometimes reaching bone, and they are among the most preventable serious injuries in long-term care.
Resident 443's care plan had no problem statement, no goal, and no interventions for the abdominal wound. It also had nothing addressing the documented high risk for pressure ulcers.
A quadriplegic resident with an open wound and a documented vulnerability to further skin breakdown, and the facility had written nothing down about how to address either one.
The inspection covered multiple days. Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted that some residents were affected. The deficiencies fell under the federal care planning requirements that govern how nursing homes are expected to manage the individual needs of the people in their care.
St. Vincent's is a Prospera community, part of a network of senior living facilities operating in North Dakota. The facility sits on North 26th Street in Bismarck, a few blocks from the Missouri River.
For Resident 443, the abdominal wound was already there when inspectors arrived. Whether it was being treated in practice, the inspection record does not say. What it says is that no plan existed on paper to guide that treatment, to set a goal for healing, or to spell out what staff were supposed to watch for. For a resident who cannot move independently and cannot advocate for repositioning or wound checks, the written plan is often the only safeguard.
It wasn't there.
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 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 flagged the gap during an April 3, 2025 survey of the nursing home at 1021 N.
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.