St. Vincent's Prospera: Transfer Notice Failures - ND
Federal inspectors who surveyed the facility on April 3 found that St. Vincent's failed to provide written transfer notices to two of six residents whose hospital transfers were reviewed. The ombudsman, whose job is to monitor exactly these kinds of facility decisions and advocate for residents, received no copies either.
The first resident, identified in inspection records as Resident 78, was transferred to a hospital on January 7. When inspectors reviewed the medical record, they found nothing, no written notice to the resident, no notice to the resident's representative, no copy sent to the ombudsman. A social services staff member at the facility confirmed it during an interview on April 2. The paperwork simply didn't exist.
The second resident, Resident 243, was transferred on March 30. A transfer notice form was eventually completed, but it was dated as delivered on April 1, two days after the transfer had already taken place. The notice arrived after the fact, which meant Resident 243 had no written documentation of the reason for the move before it happened, and no formal basis to appeal it.
The written notice isn't a formality. It is the mechanism through which residents and their families learn they have the right to contest a transfer and the right to involve the ombudsman before a decision becomes permanent. Without it, those rights exist only in theory.
St. Vincent's own policy, revised just six days before the inspection on March 28, described the requirement in plain terms. Before a transfer, the policy stated, residents and their representatives must be notified in writing of the move and the reason for it. For emergency transfers to acute care centers, notice must be provided as soon as practicable, and copies must still go to the ombudsman. The policy also required sufficient preparation and orientation so residents know where they are going and so anxiety is minimized.
The gap between that policy and what actually happened in January and March was what inspectors documented.
The inspection classified the harm level as minimal or potential for actual harm, the lower end of the federal deficiency scale. But the framing of the violation points to something harder to quantify. A resident who doesn't receive written notice doesn't know they can push back. A family member who isn't formally told the reason for a transfer can't ask the right questions. An ombudsman who never receives a copy can't identify patterns in how a facility moves its residents in and out of hospitals.
St. Vincent's, located at 1021 N. 26th Street in Bismarck, is a long-term care community operating under the Prospera brand. The inspection was completed April 3, 2025, and covered the transfer notice deficiency as the primary finding.
The social services staff member who confirmed the missing documentation for Resident 78 offered no explanation for why the notice was never produced or sent. The inspection report does not indicate whether anyone at the facility attempted to reconstruct what residents were told verbally, or whether either resident or their representative was ever reached after the fact.
Resident 243 was already in the hospital by the time the written notice was dated. Whatever that document said about rights and appeal options arrived two days too late to matter.
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 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.
Federal inspectors who surveyed the facility on April 3 found that 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.