St. Vincent's Prospera: Care Plan Violations - ND
Federal inspectors who visited the facility on April 3, 2025, found that staff had failed to include Resident #243 or a family representative in care planning meetings following his quarterly assessments on May 6, 2024, October 30, 2024, and January 30, 2025. Three separate opportunities. Nobody called. Nobody sent notice. The progress notes contained no evidence that anyone tried.
The facility sits at 1021 N. 26th Street in Bismarck. Its own policy, revised as recently as December 2, 2024, stated plainly that residents and their surrogate or proxy decision makers have the right to make decisions concerning medical care, including the right to accept or refuse treatment. The policy existed on paper. It did not exist in practice for this resident.
An administrative nurse at the facility told inspectors during an interview that afternoon that staff conduct care conferences every quarter, after a significant change, and after a hospitalization. That is what the nurse said happens. The medical record for Resident #243 showed something different. There was no documentation that he or his family had been informed in advance of changes to his plan of care, and no documentation that they had been invited to weigh in on his treatment or interventions at any of the three quarterly intervals inspectors reviewed.
Care conferences are not procedural formalities. They are the mechanism through which a resident and family learn what is being planned, ask questions, push back, and make choices. A resident who is never invited cannot refuse a treatment he finds burdensome. A family member who is never notified cannot flag a change in condition that staff may have missed, or raise a concern about a medication, or simply be present for the conversation about what comes next. When those meetings happen without the resident, decisions get made for him rather than with him.
Inspectors classified the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. The deficiency was cited under the federal requirement that nursing homes afford residents the right to participate in the development and implementation of their person-centered plan of care.
The inspection covered a single sampled resident for this particular deficiency, meaning the finding reflects what reviewers found when they looked at one chart. It does not describe how many other residents at the facility may have experienced the same exclusion.
St. Vincent's policy on advanced care planning was not an old document someone forgot to update. It had been revised four months before inspectors arrived. Whoever revised it in December 2024 presumably knew what it said. The quarterly assessment in January 2025 came six weeks after that revision. There is no record that Resident #243 or his family was contacted then either.
The facility's plan of correction was not included in the inspection materials reviewed. For information on how St. Vincent's intends to address the deficiency, CMS directs inquiries to the nursing home or the state survey agency.
What the record shows is a man whose name does not appear in this report, living on North 26th Street in Bismarck, who spent the better part of a year being cared for under plans he had no documented role in shaping. Whether anyone told him that, or whether he ever knew he was supposed to have a seat at the table, the inspection report does not say.
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.
The progress notes contained no evidence that anyone tried.
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.