St. Vincent's Prospera: Resident Abuse Failures - ND
That was two months after the incident happened.
The inspection, completed April 3, 2025, cited St. Vincent's for failing to protect residents from a man identified in the report as Resident #243, whose pattern of aggressive and inappropriate behavior toward fellow residents had gone unaddressed despite repeated complaints from the people living there.
The facility sits at 1021 N 26th St in Bismarck. It operates under the Prospera Community brand. The deficiency was cited at the level of actual harm, meaning inspectors determined residents had already been hurt, not just placed at risk.
What the inspection report describes is not a single incident that slipped through the cracks. It is a sustained pattern, documented in the facility's own records, that staff acknowledged receiving complaints about, and that management either did not know about or did not act on in any meaningful way.
Resident #243's care plan, a document the facility itself created and maintains, acknowledged that he had "a history of behavioral symptoms such as yelling and swearing at staff," that "at times he can be vulgar with his choice of words and say racist comments to the staff," and that he "refused cares." The care plan directed staff to "provide a calm, quiet atmosphere" and to "re-direct resident to not swear."
That was the plan. Re-direct him.
What the care plan did not address, inspectors found, was his explosive outbursts toward other residents, his inappropriate behaviors in shared spaces, or any strategy for protecting the people who had to eat in the same dining room, walk through the same commons area, and share the same facility with him every day.
The urination was happening in the main dining room. In emesis bags. In front of other residents. In front of family members who came to visit. Staff knew. The inspection report states that staff had been receiving complaints about behaviors in the commons area, including the public urination, and that the resident had been educated about the behavior. He continued anyway. The education did not work, and the care plan was not updated to reflect that, and no new interventions were documented.
Other residents had verbalized being fearful of him. That word, fearful, appears in the inspection report. These are people who live there, who cannot simply leave, who rely on the facility to manage the environment they inhabit around the clock. Formal complaints had been filed. The fear was not quiet or private. It was documented, reported, and apparently not elevated to the people with authority to act on it.
The January 31 incident, the one the administrator learned about for the first time when an inspector asked about it on April 3, is not described in detail in the inspection report. What is described is the gap: two months between the incident and the moment anyone in administration knew it had happened, and that moment only arrived because a federal inspector showed up and asked a direct question.
The administrator's response, captured in the inspection report, was not a defense or an explanation. It was a statement of ignorance and a promise to begin a process that should have started in January. "I didn't know about this. I will be submitting a report today and doing an investigation."
Inspectors found that the facility failed on two distinct levels. First, it failed to assess and monitor Resident #243's behavioral patterns in a way that could have protected other residents and minimized his aggression. Second, it failed to ensure that he did not infringe on other residents' rights to be free from verbal abuse. Those are not abstract regulatory categories. They describe a situation in which people living in a nursing home, people who are vulnerable and dependent and cannot leave, were subjected to racist comments, explosive outbursts, and the sight of a man urinating in a bag at the dinner table, and the facility's response was to tell him not to swear and hope for the best.
Nursing homes are required to develop care plans that actually address a resident's documented behaviors. A care plan that acknowledges a history of verbal aggression and racist language but contains no plan for protecting the people on the receiving end of that aggression is not a care plan. It is a record of a problem without a solution.
The inspection report does not say whether Resident #243 has a diagnosis that contributes to his behavior, whether he has a psychiatric consult, whether medication management has been attempted, or whether any behavioral health resources have been engaged. Those details are not in the narrative. What is in the narrative is the gap between what the facility knew and what it did.
Staff were getting complaints. Residents were filing formal complaints. People were saying out loud that they were afraid. The care plan was not updated. The behaviors were not reassessed. The January 31 incident was not reported up the chain of command. And when an inspector asked about it ten weeks later, the person responsible for running the facility said they had no idea it had happened.
The residents who filed those complaints are still living there. The dining room where Resident #243 urinated into emesis bags in front of other people is still the dining room where those residents eat their meals. The commons area where his outbursts frightened people is still the commons area where they spend their days.
The administrator promised to submit a report and start an investigation on April 3, the day the inspector asked. Whether anything changed after that is not something the inspection report can answer.
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 abuse-related violations during a health inspection on April 3, 2025.
That was two months after the incident happened.
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.