St Vincent's Prospera: Toileting Neglect Violations - ND
Federal inspectors documented the incident during an April 3, 2025 inspection of St Vincent's, A Prospera Community, on North 26th Street in Bismarck. The facility received a deficiency for failing to provide appropriate toileting assistance and perineal care for the resident, identified in inspection records as Resident #293.
His care plan was specific. Staff were directed to check him and change him every two to three hours, and as needed. He used incontinence products for heavy incontinence. He could be unaware of when he was wet or soiled. The plan existed because the facility already knew what would happen if it wasn't followed.
What inspectors observed was this: at 2:12 p.m., Resident #293 was seated in a wheelchair in the activity room. He attempted to move himself toward the hallway and told a nursing assistant he needed to go. The CNA, identified in the report as CNA #11, told him to stay there and sit down.
At 3:50 p.m., he tried again. He said he had to go and attempted to propel his wheelchair down the hallway on his own. This time two CNAs, #11 and #12, were present. Both told him to stay where he was. Neither took him to the bathroom.
Twenty-one minutes later, he was still in the activity room. He was still in his wheelchair. And urine ran down the chair and onto the floor in front of other residents and staff.
The toileting log told its own story. Staff had last taken him to the bathroom at 1:33 p.m. The next recorded toileting was at 5:00 p.m., thirty-nine minutes after the accident inspectors had watched happen. The two-to-three-hour check interval his care plan required went unmet. His requests, made out loud, in words, while physically trying to move himself toward help, went ignored.
An administrative nurse, identified as staff member #10, was interviewed the same evening at 5:18 p.m. She said she expected staff to toilet residents as care planned and as needed. She did not dispute what inspectors had seen.
The inspection report notes that moisture from incontinence softens skin and makes it more vulnerable to breakdown, erosion, and injury. Residents with heavy incontinence who are left wet face elevated risk of urinary tract infections. The consequences of skipping a toileting check are not abstract. They are skin damage, infection, and the particular kind of humiliation that comes from losing control of your body in a room full of people while two staff members watch and do nothing.
Resident #293 knew he needed help. He asked for it. He tried to get it himself when asking didn't work. The system that was supposed to catch exactly this situation, a written care plan with a specific check interval, existed on paper and nowhere else that afternoon.
The deficiency was classified as causing minimal harm or potential for actual harm, the lower end of the federal severity scale. Whether Resident #293 experienced what happened that day as minimal is not recorded anywhere in the inspection report.
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 31, 2026 · Our methodology
ST VINCENT'S - A PROSPERA COMMUNITY in BISMARCK, ND was cited for neglect violations during a health inspection on April 3, 2025.
Federal inspectors documented the incident during an April 3, 2025 inspection of St Vincent's, A Prospera Community, on North 26th Street in Bismarck.
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.