Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Miller Pointe A Prospera Co during CMS and state inspections, most recent first.
Infection control standards were not followed during observed resident care, including failures with EBP, PPE, glove changes, and hand hygiene. Staff performed wound care using the same gloves to handle clean dressings and scissors, omitted hand hygiene after PPE removal, continued perineal care and other tasks without changing gloves, and transferred residents with Foley catheters without the required gown use or proper EBP signage. Administrative staff acknowledged the infection control issues.
A resident was observed with a medication cup containing several pills on the bedside table after staff documented the morning med pass. Facility policy required staff to remain with the resident until meds were taken and swallowed unless there was a specific physician order to leave them at the bedside, and an administrative nurse stated the resident was not appropriate to self-administer medications.
Unsecured Medication Cart and Open EMR: A nurse left a medication cart on Driftwood Lane unlocked and unattended while entering a resident room, with the EMR left open and resident information visible to staff, residents, and visitors. Two insulin pens and a clear bucket containing insulin pens were observed on top of the cart, and an administrative nurse stated staff were expected to lock the cart and EMR and keep all medications stored in the cart.
Incorrect Meal Portion Sizes Served: A dietary staff member failed to serve food according to the prepared menus and tray cards for three residents during tray line service. One resident with a hx of underweight, low BMI, and weight loss risk received smaller portions than listed, and two other residents also received soup and sweet potato portions that did not match the menu or tray card instructions. The facility policy stated that portion sizes on menu extensions or tray cards are to be followed during meal service.
Staff failed to use required safety belts on the spa lift chair for two residents during bathing, contrary to facility policy and manufacturer instructions. This led to a fall and nasal fracture for a resident who required assistance for transfers and bathing, as the safety belt was not applied and the chair was not in the lowest position.
The facility failed to follow infection control standards for residents with indwelling catheters and on TBP. A provider did not use proper PPE when interacting with COVID-19 positive residents, and a resident with a catheter was not on EBP. Additionally, a CNA improperly cleaned an ileostomy bag and did not follow hand hygiene protocols. These actions were confirmed by administrative staff.
A resident fell from a mechanical lift due to improper use by staff, resulting in fractures to the right tibia and fibula. The resident, who is paraplegic, was being transferred by two staff members when one failed to properly secure the sling, causing the fall. The resident was assessed and later sent for an X-ray, which confirmed the fractures.
A resident fell from a mechanical lift due to improper handling by two staff members, resulting in a swollen knee. The facility failed to report this potential neglect incident to the State Survey Agency within the required 24-hour timeframe, as per their policy.
Infection Control Failures During Resident Care
Penalty
Summary
Infection prevention and control standards were not followed for 5 of 19 sampled residents during observed care, including failures related to enhanced barrier precautions, PPE use, dressing changes, glove changes, and hand hygiene. Facility policies reviewed stated that staff must perform hand hygiene when entering resident rooms, after removing gloves, after contact with non-intact skin or wound dressings, and when moving from a contaminated body site to a clean body site. The facility policy on enhanced barrier precautions stated that gown and gloves are used during high-contact resident care activities, including wound care and care of residents with chronic wounds or indwelling medical devices, and that clear signage should indicate the precautions and required PPE. During wound care for a resident with a left leg wound, a nurse applied gown, gloves, and a mask, removed the soiled dressing, and then used the same gloves to reach into a basket containing clean dressings and scissors, cut a new dressing, and apply it to the wound. The nurse later returned with gauze, again entered the room with PPE, readjusted the wound dressing, obtained scissors from the supply basket, cut the gauze, secured the dressing, and returned the scissors to the basket. The nurse then removed PPE and exited the room without performing hand hygiene. During morning care for another resident, a CNA completed bowel incontinence care and then, without hand hygiene or clean gloves, continued with perineal care, applied a clean brief and transfer sling, and finished cleaning the resident. The CNA later handled the resident’s dentures and glasses, straightened the room, bagged soiled linens and garbage, and exited while still holding the bagged waste in a gloved hand after only partially removing gloves and performing hand hygiene on one hand. Additional observations showed two CNAs transferring a resident with a full body mechanical lift and emptying a Foley catheter collection bag, then removing PPE and exiting without hand hygiene. Another CNA transferred a resident from a recliner to a wheelchair under enhanced barrier precautions and failed to perform hand hygiene after removing PPE. For a resident with a Foley catheter, staff observed PPE supplies outside the room but no enhanced barrier precaution sign during one observation; two CNAs entered, completed hand hygiene, applied gloves, and transferred the resident without gowns. In a later observation in the same room, a CNA emptied the urine collection bag after hand hygiene and gloving but did not apply a gown. Administrative staff acknowledged the infection control issues and stated staff should follow policy and procedures.
Medications Left at Bedside During Administration
Penalty
Summary
The facility failed to follow professional standards of practice for medication administration for one sampled resident who was observed with medications at bedside. The facility policy stated medications should not be left at the bedside or table unless there is a specific physician order, and staff should stay with the resident until the medication is taken and the resident is observed swallowing. The resident’s record included a physician’s order stating, "please make sure resident is taking medications with each med pass." During an observation, a medication cup containing several pills was seen on the resident’s bedside table. The MAR showed facility staff administered the resident’s scheduled morning medications, and an administrative nurse stated she expected staff to ensure the resident consumed all medications before leaving the room and that the resident was not appropriate to self-administer medications.
Unsecured Medication Cart and Open EMR
Penalty
Summary
The facility failed to ensure safe and secure medication storage for 1 of 6 medication carts on Driftwood Lane. The facility policy titled Medications: Storage stated that medications are to be stored in a locked medication cart, drawer, or cupboard, that carts are locked when not in use, and that carts used to transport such items are not left unattended if open or otherwise available to others. During observation, a nurse walked away from the medication cart on Driftwood Lane and entered a resident room, leaving the medication cart unlocked and unattended with the EMR left open and resident information visible to staff, residents, and visitors. The observation also showed two insulin pens and a clear bucket containing insulin pens on top of the medication cart. An administrative nurse stated that staff were expected to lock medication carts and the EMR and store all medications in the cart.
Incorrect Meal Portion Sizes Served
Penalty
Summary
The facility failed to serve food according to prepared menus for 3 of 3 sampled residents observed during tray line service. During the noon tray line, a dietary staff member served Resident #10 one-third cup of pureed stuffed pepper soup and one-third cup of mashed sweet potato, although the menu listed one-half cup of soup and one-half cup of sweet potatoes. The tray card for this resident identified two-thirds cup of soup, which did not match the menu. The same dietary staff member served Resident #11 and Resident #74 a #6 scoop of stuffed pepper soup and one-half of a baked sweet potato, while the menu and tray cards identified a six-ounce ladle of soup and one whole sweet potato. Review of the facility policy titled Portion Control stated that portion sizes listed on menu extensions or tray cards are to be followed during meal service. Resident #10's record showed a nutritional problem related to underweight, low BMI, and a history of weight loss. During interview, the dietary manager stated she expected staff to follow the ladle or scoop sizes listed on the tray cards.
Failure to Use Spa Chair Safety Belts Results in Resident Injury
Penalty
Summary
The facility failed to utilize required safety devices, specifically the spa chair safety belt, for two residents during bathing activities. In both observed cases, certified nurse aides assisted residents onto the spa lift chair and either did not apply the safety belt or did not ensure the chair was in the lowest position as required by facility policy and the manufacturer's instructions. One resident, who required assistance for transfers and bathing, was left in the spa lift chair without the safety belt and with feet elevated off the floor while being dressed. Another resident was also placed in the spa chair without the safety belt and with feet off the ground. This failure to follow established safety protocols resulted in one resident falling from the bath chair and sustaining a nasal fracture. Review of facility policy and the manufacturer's guide confirmed that safety belts are required to be used at all times when residents are in the spa lift chair. Administrative staff confirmed that their expectation was for staff to apply the safety belt and keep it in place while residents are in the chair.
Removal Plan
- Assessment and care plan changes for the residents observed, if needed.
- Education for all the bath aides as well as skill validations will be completed
- Plans for auditing the effectiveness of the training.
- Reviewed and determination the current bathing policy will remain unchanged.
Infection Control Deficiencies in PPE Use and Resident Care
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for residents with specific medical needs, including those with indwelling catheters and on transmission-based precautions (TBP). One incident involved a contract provider who did not follow the recommended personal protective equipment (PPE) protocol when interacting with COVID-19 positive residents. The provider entered a resident's room wearing only an N-95 mask, without donning a gown, gloves, or eye protection, and failed to change the mask or sanitize a stethoscope after interacting with another COVID-19 positive resident in the hallway. This breach of protocol was confirmed by an administrative nurse who acknowledged the expectation for staff to adhere to facility policies regarding TBP. Another deficiency was observed with a resident who had an indwelling catheter but was not placed on enhanced barrier precautions (EBP) as required. A nurse confirmed the presence of the catheter and the absence of EBP, indicating a lapse in following the facility's infection control policy. The policy mandates the use of gowns and gloves during high-contact care activities to prevent the transfer of multi-drug resistant organisms (MDROs). Additionally, the facility did not follow proper infection control procedures for a resident with an ileostomy. A certified nurse aide (CNA) was observed improperly cleaning an ileostomy bag by filling it with water under a bathroom sink faucet and failing to perform hand hygiene before donning new gloves. The CNA also used a walkie-talkie without changing gloves, potentially contaminating equipment. An administrative nurse confirmed that the CNA did not adhere to the expected procedures for hand hygiene and equipment cleaning.
Failure to Ensure Proper Use of Mechanical Lift Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and proper use of assistive devices, resulting in a fall incident involving a resident. The incident occurred when the resident was being transferred using a mechanical lift by two staff members. During the transfer, one staff member did not properly loop the sling on the lower left side, causing the resident to fall out of the lift. The resident, who is paraplegic, experienced a fall that resulted in a swollen right knee with an indent, although he did not report any pain due to his condition. The resident was identified as cognitively intact and capable of making decisions. After the fall, the resident was assessed by a nurse and therapy staff, and it was noted that the resident's right knee was slightly swollen. The resident was initially reluctant to seek immediate medical attention, preferring to wait for his primary care provider's scheduled visit. However, an X-ray was eventually conducted, revealing fractures in the right tibia and fibula. The incident was documented in the nursing progress notes, which detailed the sequence of events and the resident's condition post-fall. The notes indicated that the resident was transferred back to bed using the mechanical lift, and his vital signs were within normal limits. The resident's wife was informed of the incident and the subsequent medical findings. The fall team convened to discuss the incident, and the resident was later sent to the emergency room for further evaluation and treatment.
Removal Plan
- Re-educate employees involved in the incident on Safe Resident Handling and use of the mechanical lift and slings.
- Notify provider and family of the fall and provide follow up care and treatment.
- Provide education to all staff members on Safe Resident Handling, including use of various lift devices, types and sizes of slings, and mechanical lift scenarios.
Failure to Timely Report Potential Neglect Incident
Penalty
Summary
The facility failed to report an incident of potential neglect to the State Survey Agency (SA) within the required 24-hour timeframe. The incident involved a resident who fell from a mechanical lift while being transferred by two staff members. The fall occurred because the staff did not properly loop the sling on the lower left side and hook it to the lift. As a result of the fall, the resident was assessed and found to have a swollen right knee with an indent noted. The facility's policy on abuse and neglect, dated July 22, 2024, mandates that any alleged or suspected violations involving mistreatment or neglect must be reported immediately to the administrator and, in their absence, through the chain of command. The policy also requires that incidents not involving abuse but resulting in no serious bodily injury be reported within 24 hours. However, the facility reported the incident to the SA two days after it occurred, failing to comply with the established reporting timeline.
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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 Mandan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunset Drive - A Prospera Community | 3.9 mi | ★★★★★ | 9 | 0 |
| Good Samaritan Society Augusta Place A Prospera Co | 4.2 mi | ★★★★★ | 2 | 0 |
| Dakota Alpha | 4.3 mi | ★★★★★ | 0 | 0 |
| Missouri Slope | 4.4 mi | — | 0 | 0 |
| Missouri Slope | 4.7 mi | ★★★★★ | 4 | 0 |
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