St. Vincent's Prospera: Resident Left Wet After Ignored Pleas - ND
That sequence, documented by federal inspectors at St. Vincent's, a Prospera Community, unfolded on the afternoon of March 31, 2025, and sits at the center of a deficiency cited during an April inspection of the Bismarck facility.
The resident, identified in inspection records only as Resident 293, uses incontinence products for heavy incontinence. His care plan directed staff to check and change him every two to three hours and as needed, and noted he can be unaware of when he is wet or soiled. On March 31, he was apparently aware.
At 2:12 p.m., inspectors observed him seated in the activity room, attempting to propel his wheelchair, saying, "I have to go, let me go." A CNA told him to stay there and sit down.
At 3:50 p.m., he tried again, attempting to wheel himself down the hallway and repeating that he had to go. Two CNAs, both present, told him to stay there. Neither took him to the bathroom.
At 4:21 p.m., inspectors documented urine running down the wheelchair and onto the floor.
His toileting records showed staff had last assisted him at 1:33 p.m., nearly three hours before he soiled himself in front of other residents and staff in the activity room. The resident had also called the police at some point during the survey period. Officers arrived, asked a CNA whether the resident was safe, were told he was sitting at the nurses' table in his wheelchair, and left.
An administrative nurse interviewed that evening said he expected staff to toilet residents as care planned and as needed. He did not explain why it had not happened.
What the interviews with staff did explain, at least in part, was the conditions those CNAs were working in. A nurse told inspectors she was responsible for 37 to 57 residents during each shift, and that there are days she cannot complete all of her assigned duties before the shift ends. An administrative staff member said staffing levels are set based on census, and that weekends are staffed the same as weekdays, with one exception: residents are only bathed Monday through Friday.
A facility administrator told inspectors on April 3 that she expected call light wait times to run under 15 minutes, or under 20 minutes during mealtimes.
What the inspection report does not contain is any indication that the two CNAs who told Resident 293 to stay seated, twice, while he told them he needed to go, faced any documented consequence. It does not say whether he was ever told why no one helped him. It does not say whether he understood what had happened, or whether he was capable of understanding.
His care plan noted he can be unaware of when he is wet or soiled. On March 31, he knew exactly what was coming, said so out loud, tried to get there himself, and was stopped. Then it happened anyway, in the activity room, in his wheelchair, in front of everyone.
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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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 31, 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 sequence, documented by federal inspectors at 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.