Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 St Gabriel's Community during CMS and state inspections, most recent first.
The facility failed to follow its own skin breakdown policy requiring notification of the attending provider, resident, and resident representative when new pressure injuries or lower extremity wounds develop or worsen. A resident with severe cognitive impairment developed MASD to the buttocks and a heel wound that progressed from suspected deep tissue injury to an unstageable pressure ulcer with black eschar, leading to an urgent podiatry referral. The medical record contained no documentation that the resident’s representative was informed of these wounds, their progression, or new treatment orders, and the family later reported they had not been told, despite an LPN confirming that families are supposed to be notified of new wounds, changes, and related treatments.
A resident with a history of bladder cancer, hematuria, and recent antibiotic use was not accurately coded on the MDS. The facility failed to document the cancer diagnosis, internal bleeding, and antibiotic administration in the appropriate MDS sections, as confirmed by staff interview.
Staff did not follow professional standards for insulin administration and failed to notify a physician when a resident's blood glucose readings were repeatedly above the ordered threshold. Additionally, a nurse was observed priming an insulin pen incorrectly, not in accordance with manufacturer instructions.
A resident with a history of constipation and impaired mobility did not receive required bowel management interventions after going several days without a bowel movement. Despite requesting prune juice, there was no documentation that nursing staff followed the facility's bowel protocol, leading to the resident being hospitalized for fecal impaction and a urinary tract infection.
A resident with dementia and a history of wandering exited the facility unsupervised after multiple documented episodes of confusion and exit-seeking behavior. Staff did not reassess the resident's elopement risk or update the care plan with individualized interventions, resulting in the resident being found off campus by a bystander.
Staff did not consistently follow Enhanced Barrier Precautions (EBP) for two residents with indwelling Foley catheters, as required by facility policy. In both cases, staff assisted with resident transfers using gloves but failed to wear gowns during high-contact care activities, despite the expectation that gowns be used to prevent the transfer of MDROs.
The facility failed to follow infection control standards, with CNAs not performing hand hygiene between glove changes during resident care, and a nurse not donning appropriate PPE for a resident under Enhanced Barrier Precautions. These lapses were observed across multiple residents, indicating a breach in infection prevention protocols.
A resident with severe cognitive impairment repeatedly refused Ativan, an antianxiety medication, without the physician being notified. The facility lacked a policy for notifying physicians of medication refusals, and a family member expressed concern about the resident's ability to make informed decisions. A supervisory nurse was unaware if the physician had been informed of the refusals.
The facility failed to accurately code the MDS for three residents, affecting the reflection of their current status and needs. One resident's opioid medication was not coded, another's anticoagulant was incorrectly coded as an antiplatelet, and a third resident's hospice care was not recorded. Staff interviews confirmed these coding errors.
Failure to Notify Resident Representative of New and Worsening Wounds
Penalty
Summary
The facility failed to notify a resident’s representative of new and changing wounds and related treatment orders, as required by its own policy and regulatory expectations. The facility’s 2018 policy on Prevention and Treatment of Skin Breakdown required licensed nurses to perform weekly skin audits and, when a new pressure injury or lower extremity wound developed, to notify the attending provider, the resident, and the resident representative, and to educate them on the wound and care plan interventions. The policy also required notification of the attending provider, resident, and resident representative if a pressure injury failed to show progress in two weeks or deteriorated unexpectedly, with documentation reflecting these notifications. Record review for one resident with severe cognitive impairment (BIMS score of 3) identified wounds to the buttocks and right back heel, including moisture-associated skin damage (MASD) to the right medial buttock first noted as redness on 09/29/25 and later documented as new MASD with excoriation on 11/05/25. The right back heel was documented as a new suspected deep tissue injury on 11/11/25, which progressed to an unstageable pressure ulcer with mostly black eschar by 11/18/25, followed by an urgent podiatry referral order on 11/20/25. The medical record lacked documentation that the resident’s representative was notified of the buttock and heel wounds, their progression, or the new treatment orders. In interview, a family member stated they were not aware of the buttock wound or the heel ulcer, and a staff nurse confirmed that facility policy is to notify resident families of new wounds, changes in existing wounds, and related orders/treatments.
Failure to Accurately Code MDS for Resident with Cancer and Hematuria
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for one resident, as identified through record review, review of the RAI User's Manual, and staff interview. The resident had a history of hospitalizations for urinary tract infection and hematuria, with an active diagnosis of malignant neoplasm of the bladder and was prescribed Bactrim DS, an antibiotic. Despite this, the significant change and quarterly MDS assessments did not reflect the resident's cancer diagnosis in Section I0100, nor did they indicate internal bleeding in Section J1550D, even though hematuria was present. Additionally, the quarterly MDS failed to code the use of an antibiotic in Section N0415F. These omissions were confirmed during an interview with an MDS staff member, who acknowledged the failure to accurately code the MDS. The lack of accurate coding meant that the resident's assessment did not fully reflect their current status, as required by the RAI User's Manual guidelines for active diagnoses, health conditions, and medication use during the specified look-back periods.
Failure to Follow Insulin Administration Standards and Physician Notification Protocols
Penalty
Summary
Staff failed to follow professional standards of practice in the administration and management of insulin for two residents. For one resident with diabetes mellitus, physician orders required blood sugar checks three times daily and notification of the primary care provider if blood glucose exceeded 400 mg/dl or dropped below 70 mg/dl. Despite multiple documented instances where the resident's blood sugar readings were above 400 mg/dl, there was no documentation that staff notified the physician as required by the orders. Additionally, during observations of insulin administration for another resident, a nurse was seen priming an insulin pen horizontally, contrary to the manufacturer's instructions, which specify that the pen should be primed with the needle pointing up to ensure accurate dosing. The facility's policy and administrative nurse confirmed that staff are expected to follow these procedures and notify physicians of out-of-range blood sugar levels.
Failure to Follow Bowel Management Protocol Resulting in Fecal Impaction
Penalty
Summary
The facility failed to provide appropriate care and services for a resident at risk for constipation, as required by its bowel management protocol and standing house orders. The resident, who had a history of constipation and impaired mobility, did not have a bowel movement for over four days. Despite the facility's policy requiring specific interventions such as offering prune juice, administering Senna, and escalating to a bisacodyl suppository and provider notification if no bowel movement occurred, the medical record showed that these steps were not implemented. On the third day without a bowel movement, the resident requested prune juice, but there was no documentation that further protocol interventions were carried out after this request. Subsequently, the resident experienced an unresponsive episode, was found to be pale and hypotensive, and was transferred to the hospital, where they were diagnosed with a urinary tract infection and fecal impaction. The resident's bowel movement log confirmed no bowel movement occurred between the last recorded event and the hospitalization. An administrative nurse confirmed that the medical record lacked evidence of the required bowel management interventions being implemented prior to the resident's hospitalization.
Failure to Supervise and Monitor Resident with Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for a resident with a known history of dementia and wandering, resulting in an elopement incident. The resident had multiple documented episodes of confusion, wandering, and exit-seeking behaviors, including looking for her car and attempting to leave the facility. Despite these behaviors, the facility did not reassess the resident's risk for elopement or update her care plan to include individualized interventions to prevent wandering and elopement. The initial care conference did not address the resident's wandering, and staff failed to recognize and respond to the resident's escalating risk. On the day of the incident, the resident exited the facility using her wheeled walker and was later found off campus by a bystander, who notified the facility. The facility's policy required evaluation of residents' potential for wandering upon admission and as needed, but there was no documentation of a reassessment or implementation of additional interventions after the resident began exhibiting wandering and exit-seeking behaviors. The lack of timely identification and response to the resident's risk for elopement placed all residents at risk for similar incidents.
Failure to Follow Enhanced Barrier Precautions During Resident Transfers
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy for two residents who required these precautions due to the presence of indwelling Foley catheters and, in one case, a chronic wound. According to the facility's policy, staff are required to use gowns and gloves during high-contact resident care activities, such as transferring residents or providing wound care, to prevent the transfer of multi-drug resistant organisms (MDROs). For one resident, after wound care was completed with appropriate PPE, a CNA removed her gown and gloves, performed hand hygiene, and applied new gloves, but then assisted with transferring the resident using a ceiling lift without donning a gown as required by EBP protocol. In another instance, two CNAs assisted a second resident, also on EBP due to an indwelling Foley catheter, to transfer from bed to wheelchair. The CNAs wore gloves but did not wear gowns during the transfer, contrary to the facility's EBP policy. An administrative staff member confirmed during an interview that staff are expected to wear gowns during high-contact care activities for residents on EBP. These observations demonstrate that staff did not consistently follow the established infection prevention and control procedures for residents requiring EBP.
Infection Control Lapses in PPE and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection prevention and control standards, particularly in the use of personal protective equipment (PPE) and hand hygiene, for six residents. Observations revealed that certified nurse aides (CNAs) did not perform hand hygiene between glove changes during resident care activities. For instance, a CNA assisting a resident with toileting and personal care did not sanitize hands between multiple glove changes, potentially spreading contaminants. Similar lapses were observed with other residents, where CNAs failed to perform hand hygiene after handling urine collection bags and before touching other surfaces. In another instance, a CNA did not perform hand hygiene between glove changes while assisting a resident with perineal care and transferring them to a wheelchair. Additionally, a CNA was observed not changing gloves or performing hand hygiene after handling a resident's urine collection bag and before adjusting the resident in bed. These actions were contrary to the facility's hand hygiene policy, which mandates hand cleaning before and after direct resident contact and after handling soiled items. Furthermore, a staff nurse failed to don appropriate PPE when entering a resident's room under Enhanced Barrier Precautions (EBP). The nurse was unaware of the resident's precautionary status, indicating a communication lapse regarding resident care protocols. The administrative nurse confirmed the resident was still on EBP, highlighting a failure in ensuring staff compliance with infection control measures.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify the physician of a resident's repeated refusal of a prescribed medication, Ativan, which is used for anxiety and seizures. This deficiency was identified for one resident who had a pattern of refusing the medication. The lack of notification to the physician may have prevented necessary adjustments to the resident's treatment or care. The facility did not have a policy in place regarding the notification of physicians when a resident refuses medication. The resident involved had severe cognitive impairment, was sometimes understood, and had a history of rejecting care. Diagnoses included aphasia, anxiety disorder, dementia, and epilepsy. The resident refused Ativan on multiple occasions, specifically the 1:00 a.m. dose on several days and the 7:00 a.m. dose on one day. A family member expressed concern that the resident was unable to make informed decisions about medication refusal. A supervisory nurse acknowledged that the doctor should be informed of repeated refusals but was unaware if this had been done for the resident in question.
Inaccurate MDS Coding for Medications and Hospice Care
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, which is crucial for reflecting their current status and needs. For one resident, the medical record indicated a physician's order for Tramadol, an opioid, but the quarterly MDS did not reflect this medication. A nurse manager confirmed that the opioid should have been coded on the MDS. Another resident's medical record showed a physician's order for Eliquis, an anticoagulant, but the MDS incorrectly coded it as an antiplatelet. An administrative nurse acknowledged the incorrect coding in Section N of the MDS. Additionally, the facility failed to code hospice care for a resident who had a hospice consult and was receiving hospice services, as noted in the care plan. The significant change MDS did not reflect the resident's hospice care status. A nurse manager confirmed that hospice care was not coded on the MDS, indicating a lapse in accurately capturing the resident's care needs.
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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 | 0.9 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Society Augusta Place A Prospera Co | 1.2 mi | ★★★★★ | 2 | 0 |
| Baptist Health & Rehab | 1.5 mi | ★★★★★ | 0 | 0 |
| Missouri Slope | 2.9 mi | — | 0 | 0 |
| St Vincent's - A Prospera Community | 3.2 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.