Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society Augusta Place A Prospera Co during CMS and state inspections, most recent first.
The facility failed to sanitize kitchen surfaces properly, as the quaternary sanitizing solution used was below the manufacturer's recommended concentration. A dietary staff member used expired test strips, resulting in inadequate sanitization. Further testing showed the solution was below 100 ppm, leading to its disposal. An administrative staff confirmed the expectation for using up-to-date test strips and correct solution concentration.
The facility failed to follow infection control standards, with staff neglecting hand hygiene, PPE use, and equipment disinfection during resident care. These lapses involved residents with indwelling catheters, feeding tubes, and those under droplet precautions, increasing the risk of infection spread.
The facility failed to update care plans for two residents to include prescribed Hiprex medication for UTIs, limiting staff's ability to ensure continuity of care. A physician's order for one resident prescribed Hiprex to prevent UTIs, while another resident was prescribed the same for recurring UTIs. However, both care plans only included monitoring for signs and symptoms of UTIs, omitting the medication. An administrative nurse confirmed the oversight.
A facility failed to ensure proper insulin administration for a resident. A nurse was observed priming an insulin pen incorrectly by pointing it downward and not holding the injection button in while counting to ten after administration, contrary to facility policy and manufacturer's instructions. This could lead to inaccurate dosing.
A resident in a long-term care facility received the wrong type of insulin throughout the day, leading to elevated blood sugar levels and hospitalization. The error occurred because the nursing staff failed to follow the 'Six Rights' of medication administration, administering Lantus instead of the prescribed Humalog. The mistake was discovered when a nurse inquired about the insulin used, confirming the use of the incorrect pen.
A resident with arthritis, who requires supervision while consuming hot beverages, was injured when a staff member failed to secure the lid on her hot beverage cup. The resident spilled the hot liquid onto her chest, resulting in a burn. Despite having a care plan in place that required supervision and a cup with a lid, the incident occurred due to the unsecured lid.
Inadequate Sanitization of Kitchen Surfaces
Penalty
Summary
The facility failed to properly sanitize surfaces in the kitchen, as observed during a survey. A dietary staff member used a quaternary (quat) sanitizing solution to wipe a food-prep counter, but the solution was tested with expired test strips, resulting in a concentration below the manufacturer's recommended 150-400 ppm. Further testing by an administrative staff member revealed that the pre-mixed quat solutions in the kitchen were below 100 ppm, leading to their disposal. The administrative staff confirmed that the expectation was for staff to use up-to-date test strips and ensure the solution was mixed to the correct concentration.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for several residents, as observed during care and medication administration. A certified nurse aide (CNA) did not follow enhanced barrier precautions for a resident with an indwelling catheter and feeding tube, neglecting to wear a gown and failing to perform hand hygiene after glove removal. Similarly, another CNA did not remove gloves or perform hand hygiene after providing perineal care to a resident, continuing with other tasks without proper sanitation. A staff nurse did not disinfect a stethoscope after assessing lung sounds for a resident requiring enhanced barrier precautions. Additionally, a CNA failed to wear a gown while transferring a resident with an indwelling catheter, contrary to the facility's policy. A medication aide also neglected to perform hand hygiene after administering eye drops to a resident, further demonstrating lapses in infection control practices. Furthermore, a CNA did not remove a mask after providing care to a resident under droplet precautions for influenza, failing to adhere to the required personal protective equipment protocols. These observations indicate a pattern of non-compliance with established infection control policies, potentially increasing the risk of infection spread within the facility.
Failure to Update Care Plans for UTI Medication
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of two residents, which limited staff's ability to communicate needs and ensure continuity of care. For Resident #33, a physician's order dated 07/16/24 prescribed Hiprex, an antibiotic/antibacterial medication, to be taken orally twice a day to prevent urinary tract infections (UTIs). However, the care plan only included monitoring and documenting signs and symptoms of UTIs, without mentioning the medication. Similarly, for Resident #39, a physician's order dated 09/23/24 prescribed Hiprex for recurring UTIs, but the care plan also only included monitoring and documenting signs and symptoms of UTIs, omitting the medication. An administrative nurse confirmed the failure to update the care plans during an interview on 01/30/25.
Failure to Follow Insulin Administration Protocol
Penalty
Summary
The facility failed to ensure that staff followed professional standards of practice for insulin preparation and administration for one resident. During an observation, a staff nurse was seen preparing an insulin pen for a resident's Lantus insulin administration. The nurse did not follow the facility's policy or the manufacturer's instructions, as she primed the insulin pen with the needle pointing downward towards a garbage can instead of upwards. Additionally, after administering the insulin, the nurse immediately removed the needle from the resident's skin without holding the injection button in and counting to ten, as required by the manufacturer's instructions. The facility's policy on insulin administration, revised in September 2024, clearly outlines the correct procedure for priming and administering insulin using a pen. The policy states that the pen should be primed with the needle pointing upwards and that the injection button should be held in while counting to ensure the full dose is delivered. An administrative nurse confirmed during an interview that the staff is expected to follow these procedures. The failure to adhere to these standards could result in the resident receiving an inaccurate dose of insulin.
Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that a resident remained free from significant medication errors, specifically in the administration of insulin. On the day of the incident, the resident was supposed to receive Humalog, a fast-acting insulin, according to their physician's orders. Instead, the resident was administered Lantus, a long-acting insulin, multiple times throughout the day. This error in medication administration was identified when the resident's blood sugar levels were recorded as significantly elevated at various times, leading to the resident being sent to the emergency room for monitoring. The error was discovered when a nurse coming on duty inquired about the insulin administered to the resident, and it was confirmed that the wrong insulin pen was used. The resident's blood sugar levels were recorded at 379 mg/dl in the morning, 456 mg/dl by late morning, and 566 mg/dl in the afternoon, indicating a failure to manage the resident's blood sugar levels effectively. The incident was attributed to the nursing staff's failure to adhere to the 'Six Rights' of medication administration, resulting in the resident receiving the incorrect type of insulin.
Failure to Secure Hot Beverage Lid Results in Resident Burn
Penalty
Summary
The facility failed to ensure an environment free of hazards, resulting in an injury to a resident who was consuming a hot beverage. The resident, who has impaired ability to manage hot beverages due to arthritis in her hands and shoulder, was provided with a hot beverage with a loosened lid to allow it to cool. However, the staff did not secure the lid properly, and the resident, forgetting to wait for assistance, spilled the hot liquid onto her chest, causing a burn. The resident's care plan indicated that she required supervision while drinking hot beverages and that a cup with a lid should be provided. Despite these interventions being in place, the incident occurred due to the failure to secure the lid on the hot beverage cup. The resident sustained a burn on her chest, which was initially red and later developed into a blister. The incident was reported, and the resident was assessed by a nurse and later by a provider, who prescribed treatment for the burn.
Removal Plan
- Completing an investigation that determined the primary cause of the accident (not securing the lid to the hot beverage cup).
- Provided education immediately to all staff through a text communication stating facility staff are to ensure all hot liquid covers are securely fastened before giving them to residents to prevent injury and burns.
- Interview with two administrative staff members and a corporate staff member identified the facility will reiterate hot beverage safety at the next CNA meeting.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Bismarck
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Missouri Slope | 0.7 mi | ★★★★★ | 4 | 0 |
| St Gabriel's Community | 1.2 mi | ★★★★★ | 1 | 0 |
| Baptist Health & Rehab | 1.9 mi | ★★★★★ | 0 | 0 |
| Missouri Slope | 2.6 mi | — | 0 | 0 |
| St Vincent's - A Prospera Community | 3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.