Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Missouri Slope during CMS and state inspections, most recent first.
Staff failed to follow infection control practices during resident care, including EBP use, hand hygiene, glove changes, catheter bag handling, and equipment disinfection. A nurse did not wear a gown for high-contact device care for a resident on EBP, a Foley catheter bag was allowed to drag along the floor, and CNAs handled soiled and clean tasks without proper hand hygiene or disinfection of contaminated items and surfaces.
Improper Sit-to-Stand Lift Transfer: Two CNAs assisted a resident with left-sided weakness, paralysis, and a history of falls during a PAL transfer. The resident was raised to standing while the abdominal strap buckle and leg straps were not secured, and morning care was provided while the resident remained connected to the lift.
Medications and biologicals were not securely stored for two residents with items left at the bedside. A topical analgesic and multiple eye drop bottles were observed in one resident's room, and Lidocaine patches, eye drops, psyllium husk powder, and muscle rub cream were observed in another resident's room. An admin staff member confirmed nursing staff were not aware of the medications in either room.
A resident with dementia was physically and verbally abused by a CNA during evening care. The resident, who has a history of anxiety disorder and Alzheimer's, was slapped and had their head covered with a blanket after exhibiting dementia-related behaviors. Another CNA witnessed the incident but delayed reporting it due to fear of retaliation, resulting in a failure to promptly address the abuse and assess the resident for injuries.
A resident with limited mobility fell and fractured their right humerus after a CNA removed the whirlpool seat belt prematurely, contrary to facility policy. The resident was found on the floor with a head injury and bleeding. Interviews confirmed the CNA should have kept the safety belt on, as per training instructions.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
The facility failed to follow infection control and prevention standards for Resident #30, Resident #50, Resident #61, Resident #139, and Resident #154. Review of facility policies showed expectations for hand hygiene, glove removal, linen handling, catheter care, and Enhanced Barrier Precautions (EBP), including gown and glove use for high-contact direct care and device care. Resident #30 had an indwelling medical device and was on EBP; during observation, a nurse performed hand hygiene and applied gloves before flushing the feeding tube and reattaching it to the pump, but did not apply a gown for the high-contact care. Resident #50 had recurrent UTIs and a Foley catheter; during observation, the urine collection bag slid along the floor as the resident drove a motorized wheelchair, and staff did not secure the bag until the resident reached the room. For Resident #61, one CNA and another CNA handled soiled gloves and clean gloves without proper hand hygiene between tasks, and later a CNA placed soiled washcloths on the bedside table and did not disinfect the table after use. For Resident #139, a CNA placed a soiled washcloth on the bedside table and did not disinfect the table afterward. For Resident #154, a CNA changed gloves during brief care but did not perform hand hygiene between glove changes and did not remove soiled gloves and complete hand hygiene before exiting the room.
Improper Sit-to-Stand Lift Transfer
Penalty
Summary
The facility failed to ensure adequate assistance for one sampled resident during a mechanical sit-to-stand lift transfer. The resident had diagnoses including left-sided weakness and paralysis, a history of falling, unsteadiness on feet, and abnormal posture. The care plan directed transfers with a patient assist lift with assistance of two staff, and the shared risk agreement noted the resident could choose where the hook strap length was set and where the abdominal strap was located, with a preference for it above the abdomen. During observation, two CNAs assisted the resident to the edge of the bed, placed the lift sling under the resident's arms, and positioned the mechanical lift in front of the resident. The CNA stated the resident did not want the abdominal strap buckled. The resident held onto the lift with only the right hand, and the CNAs raised the resident to a standing position without securing the abdominal strap buckle or the leg straps. The CNAs then provided morning care while the resident remained standing connected to the sit-to-stand lift. An administrative nurse stated staff were expected to always buckle the abdominal safety straps on the sling and secure the leg straps on the PAL lift.
Medications Left at Bedside Without Secure Storage
Penalty
Summary
Drugs and biologicals were not stored securely for one sampled resident and one supplemental resident with medications at the bedside. On 05/11/26, a tube of topical analgesic was observed on Resident #24's bedside table, and on 05/12/26, three Refresh Tears eye drop bottles and one Systane eye drop bottle were observed on the same resident's bedside table. During an interview on 05/14/26, administrative staff member #5 confirmed nursing staff were not aware of the medications in Resident #24's room. For Resident #109, a box of Lidocaine patches and Genteal eye drops were observed at the bedside on 05/11/26, and on 05/12/26, Lidocaine patches, Genteal eye drops, generic psyllium husk powder, and generic muscle rub cream were again observed at the bedside. During an interview on 05/14/26, administrative staff member #3 confirmed nursing staff were not aware of the medications in Resident #109's room.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by a certified nurse aide (CNA). The incident involved a resident with a medical history of anxiety disorder, dementia with mood disturbances, and Alzheimer's disease. During evening care, the resident exhibited verbal and physical behaviors related to dementia, such as yelling and spitting at the CNA. In response, the CNA slapped the resident and covered their head with a blanket, claiming it was a method to calm the resident. This abusive behavior was witnessed by another CNA, who did not report the incident immediately due to fear of retaliation. The delay in reporting the abuse incident resulted in a failure to promptly remove the accused CNA, initiate a facility investigation, and assess the resident for potential injuries. The facility's policy on abuse, which mandates immediate reporting of any mistreatment, was not followed. The managerial staff later confirmed that the witnessing CNA received education on the importance of immediate reporting, highlighting a gap in adherence to the facility's abuse prevention protocols.
Failure to Use Whirlpool Seat Belt Results in Resident Fall and Fracture
Penalty
Summary
The facility failed to prevent an accident involving a resident who sustained a fall and fracture due to the improper use of a whirlpool seat belt. The facility's policy on bathing procedures required the use of a safety strap when transferring a resident to a whirlpool seat, but it did not provide clear instructions on when it was safe to remove the seat belt. During an incident, a certified nurse aide (CNA) removed the seat belt while the resident was still elevated, resulting in the resident slipping from the tub chair onto the floor. This led to the resident sustaining a right humerus fracture and a head injury with bleeding. The resident involved had a care plan indicating a self-care performance deficit and limited physical mobility related to deconditioning weakness. The incident was documented in a progress note, which described the resident being found on the floor with injuries. Interviews with the resident and an administrative nurse confirmed that the CNA should have kept the safety belt on, as instructed in training. The failure to maintain the appropriate safety measures during the whirlpool bath directly contributed to the resident's fall and subsequent injuries.
Removal Plan
- Completing investigations following fall
- Determining the CNA failed to ensure adequate supervision of resident during whirlpool bath
- Educating/re-educating bath aides regarding utilizing the whirlpool chair seat belt while completing resident baths
- Adding Whirlpool Safety Checklist to the lead CNA's job duties
- Adding Whirlpool Safety Performance Tracker as a quality assurance measure
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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) |
|---|---|---|---|---|
| Good Samaritan Society Augusta Place A Prospera Co | 0.7 mi | ★★★★★ | 2 | 0 |
| St Gabriel's Community | 0.9 mi | ★★★★★ | 1 | 0 |
| Baptist Health & Rehab | 2.2 mi | ★★★★★ | 0 | 0 |
| Missouri Slope | 3.2 mi | — | 0 | 0 |
| St Vincent's - A Prospera Community | 3.6 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.