St. Vincent's Prospera: Wheelchair Fall on Van Ramp - ND
The fall happened on the morning of October 11, 2024. The resident was Resident 243, a wheelchair user whose chair was equipped with anti-rollback devices, the small brackets that lock against a ramp surface to prevent a chair from sliding backward or forward on an incline. When he fell, those devices were not properly positioned.
The driver called 911. Clinic staff arrived and stayed with the resident until EMS came. A progress note entered that afternoon, at 4:28 p.m., recorded what the resident told staff afterward. He denied pain, nausea, and dizziness. He described the incident and said he thought he may have landed on the back of his head. No lump or bruising was visible. He asked for Tylenol and a muscle relaxant.
The inspection, completed April 3, 2025, cited the facility under F689, the federal tag covering accident hazards and supervision. CMS classified the harm level as minimal, with few residents affected. The deficiency was recorded as past non-compliance, meaning the facility had already taken corrective steps before inspectors arrived.
What the facility found when it looked into the fall was that no care plan for any resident with an anti-rollback wheelchair addressed how or when those devices were supposed to be used during van transfers. There was nothing written down. No instruction telling drivers to position the brackets upward while loading and unloading, and downward once the resident was seated inside the van or clear of the ramp. That protocol didn't exist anywhere in writing until after Resident 243 fell.
After the incident, the facility went through every resident wheelchair in the building, identified which ones had anti-rollbacks, and added language to each affected care plan. The new care plan entry specified exactly when the devices were to be engaged: upward while going up or down the ramp, downward once the transfer was complete. Drivers received retraining and competency evaluations on the same day as the fall. The facility also started conducting audits of van transfers.
The investigation report the facility submitted described those steps plainly, without much elaboration. It confirmed the care plan update, the retraining, the audits. It did not address why the protocol had never been written down before, or how long residents had been transported in vans without any documented standard for the anti-rollback devices.
The driver's uncertainty about whether Resident 243's head struck the ramp floor was noted in the inspection record and left unresolved. The progress note from that afternoon suggested the resident himself wasn't sure either, saying only that he thought he may have landed on the back of his head. No lump. No bruising. A request for Tylenol and something for muscle pain.
St. Vincent's - A Prospera Community operates at 1021 N 26th St in Bismarck.
For a man who spent part of an October morning on a van ramp, possibly with the back of his head against the floor, the paperwork that followed was tidy. The care plans were updated. The drivers were retrained. The audits began. What it took to get there was a fall that nobody, including the person who was there, could fully account for.
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.
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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.
The fall happened on the morning of October 11, 2024.
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.