Sunset Drive - A Prospera Community
Sunset Drive - a Prospera Community in Mandan, ND — inspection on May 28, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #19's medical record occurred on all days of survey and identified family member #B as the resident's guardian over the person, financial and property, effective 03/19/26.Review of Resident #19's progress notes identified the following:*03/28/2026 at 9:47 p.m., Resident left AMA [against medical advice].*03/28/26 at 9:55 p.m., Resident not in her room since this nurse came around 1800 [6:00 p.m.] until this time.
Called [family member C] and asked about her mother and told this nurse that 'My mom wants me to take care of her in our house' and dropped the phone.
Resident left AMA in the facility without notifying staff and without signing the sign out sheet.
During an interview on 05/26/26 at 4:19 p.m., family member B confirmed the facility did not call her when the resident left the facility and did not return and stated the administrative staff member (#4) and an unknown nurse received the guardianship paperwork on 03/26/26.
The facility failed to notify the guardian after Resident #19 left the facility.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
355065 05/28/2026
Sunset Drive - A Prospera Community 1011 Boundary St NW Mandan, ND 58554
a family member cleaned their room on multiple occasions.
dirty, the bed wouldn't be made until after 1:00 p.m., and the mess from the night before would still be
-
During an interview on 05/28/26 at 3:01 p.m., an environmental staff member (#7) confirmed the housekeeping department is short staffed.
355065 05/28/2026
Sunset Drive - A Prospera Community 1011 Boundary St NW Mandan, ND 58554
Review of the FRI, submitted to the state survey agency (SSA) on 04/28/26, identified a moderate injury and compression to the T8 (thoracic vertebrae number 8).
The report stated [Resident #20] states she was dropped from mechanical lift, staff deny incident no one notified.
When PA [physician's assistant] was told on 4/27 x-rays ordered.
Resident has significant hs [history] of back pain .
Review or Resident#20's medical record occurred on all days of survey. A quarterly Minimum Data Set (MDS), dated [DATE], identified intact cognition.
The current care plan stated, . has an ADL [activities of daily living] self care performance deficit R/T [related to] weakness . needs assistance for transfers .
Transfer - sit to stand assist x 1 [one person assist].
Review of Resident 20's nurses' notes identified the following: *04/26/26 at 18:24 (3:15 p.m.), stated, The [family member D] called and said that the resident is telling that he (sic) had a fall on Friday -04/24/2026 from the sling of the lift. *04/27/26 at 10:09 a.m., stated, [provider's name] here and informed of resident stating that she had fallen on friday (sic) and c/o [complains of] severe pain all over. no record of resident falling friday (sic) or c/o pain. new order for thoracic/lumbar/spine x-ray.
During an interview on 05/28/26 at 8:36 a.m., a family member D stated she called the facility on Saturday, 04/25/26, and asked the nurse about Resident #20's report of a fall.
The nurse told family member D there were no reported falls.
Family member D stated she called the facility again on Sunday, 04/26/26, and told a nurse Resident #20 complained of pain and said she fell.
The nurse told family member D the resident could not have fallen.
During an interview on 05/28/26 at 12:04 p.m., an administrative nurse (#6) stated facility staff informed her of the fall on 04/024/26 but Resident #20 could not recall when it happened.
The fall did not seem real therefore, the facility did not conduct an investigation.
The facility failed to investigate Resident #20's reported fall from a mechanical lift or the cause of the compression fracture to her T8 vertebrae.
355065 05/28/2026
Sunset Drive - A Prospera Community 1011 Boundary St NW Mandan, ND 58554
Observation on 05/27/26 at 9:10 a.m., an unidentified certified nurse aide (CNA) approached Resident #2, who was seated in his wheelchair.
The CNA brought Resident #2 back to his room to assist with dressing.
During the transport, the resident's legs/feet bounced along the floor.
The CNA failed to place the footrests on the wheelchair and failed to cue the resident to raise his legs/feet.
355065 05/28/2026
Sunset Drive - A Prospera Community 1011 Boundary St NW Mandan, ND 58554
Review of Resident #18's medical record occurred on all days of survey and identified an admission from the hospital to the facility on [DATE].
Diagnoses included interstitial pulmonary disease, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen.
The resident's baseline care plan lacked problems, goals or interventions related to respiratory diagnoses.
Review of a pulmonary inpatient consultation note, dated 04/20/26 (prior to admission to the facility), stated, . began to require supplemental oxygen earlier this year. currently using about 3 L [liters]/min [minute]. A chest CT scan during this admission showed interstitial lung disease . CT [computed tomography] scan shows progression.
Recommendations. increase her oxygen to the maximum before she exerts herself.
Plan includes supportive care, symptom management, and rehabilitation at a nursing facility for breathing therapy.
Review of Resident #18's discharge summary note, dated 05/01/26 stated, Discharge Diagnoses .
Dependence on supplemental oxygen .
Hypoxia.
Pulmonology consulted . recommend increasing her oxygen to maximum over 4 she exerts herself. history of chronic hypoxic respiratory failure, interstitial lung disease, pulmonary hypertension at baseline 3-1/2 L to 4 L O2 [oxygen] .
Review of Resident #18's progress notes identified the following: *05/01/2026 at 5:03 p.m., . O2 90% [oxygen saturation percent] .
Method: Room Air.
Resident reported Shortness of breath (while lying flat).
Nurse observed Shortness of breath (upon exertion). *05/05/2026 at 8:19 a.m., CNA alerted writer that [resident name] was having shortness of breath. visibly short of breath, anxious, posture was leaned forward. O2 SAT [saturation] 76% on 2L. [resident stated] 'I have been crying most of the night.' NOC [night] nurse did not report this.
Unaware if she placed call light to report . TO [telephone order] to transfer to ER [emergency room] . *05/05/2026 at 9:02 a.m., Writer does recall the night nurses reporting she had placed resident on a concentrator as the oxygen did not seem to be working.
The facility failed to clarify post hospitalization orders and whether Resident #18 required oxygen, and if so, at what flow rate; and failed to assess and/or address the resident's change in respiratory status.
These failures may have contributed to Resident #18's rehospitalization just four days after admission to the facility.
During an interview on 05/28/27 at 12:49 p.m., an administrative staff member (#1) confirmed staff failed to obtain a physician's order for oxygen therapy and monitoring.
355065 05/28/2026
Sunset Drive - A Prospera Community 1011 Boundary St NW Mandan, ND 58554
Review of the facility policy titled Standard, Enhanced Barrier, and Transmission-Based Precautions .' occurred on 05/28/26.
This policy, dated 04/30/26, stated, .
Enhanced Barrier Precautions (EBP) .
Enhanced barrier precautions expand the use of personal protective equipment beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant (MDROs) to staff hands and clothing. -Review of Resident #21's medical record occurred on all days of survey.
The care plan stated, . EBP.
The resident requires Enhance Barrier Precautions (EPB) .
Doff [put on] gown and gloves inside resident room.
Perform hand hygiene.
Observation on 05/26/26 at 3:16 pm, showed a certified nurse aide (CNA) (#8) entered Resident #21's room, performed hands hygiene, applied gloves, and without applying a gown, transferred the resident to the toilet.
The CNA changed the wet brief and pants, provided perineal care, and transferred the resident back to the wheelchair. -Observation on 05/26/26 at 4:32 p.m. showed two CNAs (#2 and #3) performed hand hygiene and applied gowns and gloves prior to entering Resident #8's room, identified as EBP.
The CNAs transferred the resident to a wheelchair with a full body mechanical lift.
After the transfer, one CNA (#2) reached into her pocket with a gloved hand, asked for assistance over the radio, and placed the radio back into her pocket.
The CNA (#2) failed to disinfect the radio after exiting the resident's room.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.