Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Vincent's - A Prospera Community during CMS and state inspections, most recent first.
The facility failed to prevent abuse and neglect, as one resident experienced rough handling and emotional distress from CNAs, including being pulled by the neck and sustaining an undocumented bruise. Additionally, another resident with behavioral health issues repeatedly exhibited aggressive and inappropriate behaviors, such as verbal threats, swearing, and public urination, causing fear and anxiety among peers. The care plan did not address these behaviors, and staff were unaware of key incidents, resulting in an unsafe environment.
A resident with dementia and anxiety received frequent PRN Ativan administration for behaviors such as restlessness and agitation, without prior assessment of behavioral causes or implementation of non-pharmacological interventions. The care plan did not specify individualized strategies, and observations showed the resident was often unresponsive and required assistance for transfers, indicating a failure to prevent unnecessary use of psychotropic medication and chemical restraint.
Surveyors found that food was frequently served at unacceptable temperatures, with multiple residents reporting that their meals were cold or lukewarm, especially when delivered to rooms. Direct observations and a test tray confirmed that hot foods were not maintained at appetizing temperatures, in violation of facility policy.
Surveyors found thick black dust and dirt on fans, ceilings, and walls in the walk-in cooler and freezer, as well as peeling duct tape on an oven handle, making it non-cleanable. An administrative dietary staff member confirmed these unsanitary conditions and acknowledged staff responsibility for cleaning these areas.
The facility did not establish or maintain an effective QAPI process, resulting in ongoing deficiencies related to care plan revisions, nursing staff sufficiency, medication management, food quality and safety, and infection control. Despite administrative staff conducting audits and developing a plan of correction, these quality assurance activities did not prevent continued noncompliance.
Surveyors found that care plans were not updated or revised to reflect the current needs of several residents, including those with frequent behavioral issues requiring PRN medication, new skin lesions treated with antibiotics, aggressive behaviors and diabetes management needs, and a high risk for pressure ulcers due to wounds and immobility. These deficiencies limited staff communication and continuity of care.
The facility did not ensure adequate nursing staff to meet resident needs, resulting in multiple residents experiencing prolonged delays in call light responses, missed or delayed meals, and inadequate toileting assistance. Staff were observed not assisting residents as care planned, and documentation confirmed extended wait times for help, with some residents left in discomfort or unable to access their call lights. Staff interviews revealed high resident-to-nurse ratios and consistent staffing shortages, especially during shift changes and weekends.
A resident who required staff assistance for toileting was not provided timely help despite repeated requests, resulting in an incontinent episode in a public area. Staff did not follow the care plan for scheduled toileting and perineal care, and documentation showed significant delays between toileting opportunities.
Nursing staff conducted blood glucose checks and administered insulin injections to two residents in a common area, exposing them to observation by other residents and staff, rather than providing privacy as required by facility policy.
Facility staff did not ensure that a resident or their family representative was invited to participate in care conferences or informed of changes to the care plan, as required by facility policy. Medical records lacked documentation of invitations or involvement in care planning after admission, quarterly assessments, or hospitalizations, restricting the resident's right to provide input on care decisions.
The facility did not immediately report allegations of staff roughness and a resident-to-resident verbal altercation to the administrator or State Survey Agency, as required by policy. One resident and a family member described rough handling and disregard for requests, while another resident with cognitive and mental health diagnoses was involved in a threatening exchange with a peer. Facility staff failed to recognize and report these incidents as potential abuse.
The facility did not thoroughly investigate reports of staff roughness and a resident's injury during care, nor did it address a verbal altercation between two residents involving threats and profanities. Documentation lacked details of the allegations and investigations, and administrative staff were unaware of some incidents, resulting in a failure to protect residents and implement corrective actions.
Facility staff did not complete a significant change in status assessment (SCSA) for a resident who experienced a decline in activities of daily living and weight loss. The resident required increased assistance with oral hygiene and footwear, but staff did not identify or document the need for a SCSA as required by the RAI 3.0 guidelines.
Staff did not notify the primary care provider when a resident with type 2 diabetes had blood glucose readings above the ordered threshold, as required by physician orders. Documentation showed no evidence of provider notification for two critically high blood sugar results, and this was confirmed by administrative staff.
Two residents who required assistance with transfers were not provided with proper assessment or use of assistive devices, such as gait belts and mechanical lifts, as specified in their care plans. In one case, a CNA manually transferred a resident without a gait belt, and in another, staff used a sit-to-stand lift on an unresponsive resident without documented assessment of safety. Additionally, a resident fell during a van transfer when anti-rollbacks on the wheelchair were not properly positioned, resulting in the resident being lowered to the ramp floor. These incidents occurred due to lack of adherence to established policies and insufficient documentation or assessment by licensed staff.
A nurse failed to reconcile and report a discrepancy in the morphine sulfate count for a resident, as the narcotic count sheet showed remaining medication but the bottle was empty. Facility policy requires immediate reconciliation and reporting of such discrepancies for controlled substances, which was not followed in this case.
Staff failed to follow infection prevention protocols for two residents: one requiring Enhanced Barrier Precautions due to a urinary catheter, where a CNA did not wear a gown during high-contact care, and another with a history of UTIs, where perineal care was performed incorrectly and double briefing occurred. Administrative staff confirmed these practices did not meet facility policy.
The facility did not consistently post accurate daily nurse staffing information as required, with staffing reports on two survey days displaying incorrect dates. This failure was observed and confirmed through policy review and direct observation.
Failure to Protect Residents from Abuse and Inadequate Response to Aggressive Behaviors
Penalty
Summary
The facility failed to protect a resident from physical and mental abuse, as evidenced by multiple incidents involving rough handling by certified nurse aides (CNAs). One resident, with diagnoses including vertigo and left-sided hemiplegia/hemiparesis, required substantial assistance for activities of daily living and was care planned for sit-to-stand lift transfers when experiencing vertigo. Despite this, the resident and a family member reported that some CNAs were rough during care, and that expressing concerns about this roughness led to even rougher treatment. Specific incidents included the resident's hands being hit against side rails and door frames during transfers, and being pulled to a sitting position by the back of the neck. The resident expressed fear of retaliation from a CNA and reported emotional distress about being a burden to staff. A bruise was observed on the resident's left hand, which the resident attributed to a transfer incident about a week prior, but there was no documentation of this injury in the medical record. An administrative nurse was aware of the abuse allegation but not the bruise. The facility also failed to protect residents from abuse by another resident who exhibited explosive outbursts and inappropriate behaviors. This resident, with a history of anxiety, stroke, dementia, and a mental disorder requiring continuous supervision, displayed repeated episodes of verbal aggression, swearing, urinating in inappropriate places in communal areas, and making threatening or demeaning comments to other residents. Progress notes documented multiple incidents where the resident's behavior caused distress and fear among other residents, including threats of physical violence, use of foul language, and inappropriate urination in front of others. Staff and other residents reported feeling unsafe and anxious due to these behaviors, and there were requests from residents and family members to file formal complaints. Despite the ongoing behavioral issues, the resident's care plan only addressed yelling and swearing at staff, with interventions limited to providing a calm atmosphere and redirecting the resident. The care plan did not address the resident's aggressive and inappropriate behaviors toward other residents. An administrative staff member was unaware of at least one significant incident and had not initiated an investigation until prompted. The facility did not adequately assess, monitor, or implement effective interventions to minimize the risk of abuse and protect residents from harm caused by this individual's behaviors.
Failure to Prevent Unnecessary Use of Psychotropic Medication and Chemical Restraint
Penalty
Summary
The facility failed to prevent the unnecessary use of psychotropic medications and did not ensure that a resident remained free from chemical restraints. A resident with diagnoses including vascular dementia, anxiety disorder, Alzheimer's disease, restlessness, and agitation was prescribed Ativan on a PRN basis for restlessness, agitation, and anxiety, with subsequent orders increasing the frequency and scheduling of the medication. Over a period of approximately 73 days, staff administered PRN Ativan 50 times for behaviors such as restlessness, agitation, rudeness to staff, refusing care, aggression, and wanting to leave the facility. Observations showed the resident was frequently unresponsive and asleep during the day, requiring physical assistance for transfers and toileting. The facility did not assess the resident's behaviors to determine causative or precipitating factors, nor did it develop a behavioral care plan or implement individualized non-pharmacological interventions prior to administering PRN Ativan. The care plan lacked specific details regarding the resident's behaviors and non-pharmacological strategies. Despite documentation from behavior and mood team meetings indicating no new concerns or improvements, the frequent use of Ativan continued, and the resident exhibited increased sleeping and decreased responsiveness.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
Surveyors identified that the facility failed to serve food at palatable and appetizing temperatures across three units. Review of facility policies confirmed that meals are required to be served at proper temperatures, with procedures in place for test tray monitoring to ensure compliance. Despite these policies, multiple resident interviews and direct observations revealed that both hot and cold foods were frequently served at temperatures that were not acceptable to residents. Several residents reported that their meals, especially when served in their rooms, were often cold or lukewarm, and one resident specifically noted that toast was always cold due to being prepared ahead of time. Observations also showed residents waiting for food to be reheated or expressing dissatisfaction with the temperature of their meals. A test tray conducted by surveyors further substantiated these concerns, with food items such as chicken, zucchini, and pasta measured at temperatures below what would be considered hot and appetizing. The surveyors themselves confirmed that the food was lukewarm rather than hot. These findings demonstrate a consistent failure to maintain food temperatures from preparation to service, resulting in meals that did not meet the facility's own standards for palatability and temperature.
Unsanitary Kitchen and Cold Storage Conditions
Penalty
Summary
Surveyors observed that the facility failed to maintain cold storage areas and kitchen equipment in a sanitary condition. Specifically, there was a significant accumulation of thick, dark black dust and dirt on the fans and surrounding ceiling and wall areas in both the walk-in cooler and freezer. Additionally, the handles of a reach-in oven were covered with peeling and tattered duct tape, creating a surface that could not be properly cleaned. These conditions were noted during both the initial and final observations of the kitchen. During an interview, an administrative dietary staff member confirmed the presence of the peeling duct tape on the oven doors and acknowledged that staff were expected to clean the black dust and dirt from the fans, walls, and ceilings in the walk-in cooler and freezer. The observations and staff confirmation indicate that the facility did not adhere to professional standards for food storage and equipment sanitation, as outlined in the 2022 FDA Food Code.
Failure to Implement Effective QAPI Process
Penalty
Summary
The facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems, improve services and outcomes, and ensure compliance with federal requirements. Review of the facility's QAPI policy indicated that while the policy described using data to monitor services and identify improvement opportunities, the facility did not maintain compliance in several key areas, as evidenced by deficiencies cited during the last standard survey. These deficiencies included issues with care plan revisions, sufficient nursing staff, medication labeling and storage, palatable foods, food storage and preparation, and infection control. Interviews with two administrative staff members revealed that although they developed a plan of correction and conducted audits, the facility's quality assurance activities were not effective in preventing continued noncompliance in these areas.
Failure to Update and Revise Care Plans for Multiple Residents
Penalty
Summary
The facility failed to review and revise care plans to accurately reflect the current status and needs of several residents, as required by policy. For one resident with dementia and anxiety, staff administered PRN Ativan 50 times over approximately 73 days for behaviors such as restlessness, agitation, aggression, and refusal of care, but the care plan did not specify these behaviors or detail appropriate non-pharmacological interventions. Another resident developed skin lesions and was prescribed topical and oral antibiotics, yet the care plan did not address these new skin issues or the use of antibiotics. A third resident, diagnosed with Alzheimer's disease, anxiety, and diabetes, exhibited aggressive and disruptive behaviors toward others and required insulin for diabetes management. However, the care plan did not address these behaviors or the management and complications of diabetes. Additionally, a resident with quadriplegia and an abdominal wound, identified as being at high risk for pressure ulcers, did not have a care plan that included problems, goals, or interventions related to the wound or pressure ulcer risk. These omissions limited staff communication and continuity of care.
Failure to Provide Sufficient Nursing Staff and Timely Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple observations, interviews, and record reviews. Residents and family members reported frequent and prolonged delays in call light responses, with several residents waiting 30 minutes to an hour for assistance, particularly during shift changes, evenings, and weekends. Call light logs confirmed that some residents experienced wait times exceeding 20 minutes on numerous occasions, with the longest documented wait being 59 minutes. Residents also reported missed or delayed meals, lack of timely toileting assistance, and instances where call lights were not placed within reach, resulting in residents being unable to summon help when needed. Specific incidents included a resident who called the police due to excessive wait times for assistance, and another resident who was left in soiled incontinence products for several hours, despite care plans indicating the need for regular checks and changes. Observations showed staff instructing a resident to remain seated and not assisting with toileting, which led to the resident urinating on themselves and the floor. Documentation revealed that staff did not toilet the resident for nearly three hours, contrary to the care plan requirements. Staff interviews indicated that nurses were responsible for large numbers of residents per shift, sometimes up to 57, and that staffing levels did not vary between weekdays and weekends, except for bathing schedules. Administrative staff acknowledged expectations for call light response times to be under 15 minutes, or under 20 minutes during mealtimes, but evidence from logs and interviews demonstrated that these expectations were not consistently met. The facility's own assessment and policies emphasized the need for prompt response and adequate staffing, but these standards were not upheld in practice.
Failure to Provide Timely Toileting Assistance and Perineal Care
Penalty
Summary
Facility staff failed to provide appropriate toileting and perineal care for a resident who required staff assistance. The resident's care plan specified the need for check and change, use of incontinence products for heavy incontinence, and toileting every 2-3 hours and as needed. On the day of observation, the resident, who was seated in a wheelchair, expressed the need to use the bathroom multiple times and attempted to self-propel towards the restroom. Despite these requests, staff instructed the resident to remain seated and did not provide assistance to the bathroom. Subsequently, the resident experienced an incontinent episode, with urine running down the wheelchair and onto the floor in the activity room. Documentation showed the resident was last toileted over two hours prior to the incident and was not assisted again until nearly 40 minutes after the episode. An administrative nurse confirmed that staff are expected to toilet residents as care planned and as needed, but this did not occur in this instance.
Insulin Administration and Blood Glucose Checks Performed Without Resident Privacy
Penalty
Summary
Nursing staff failed to maintain resident dignity and privacy during the administration of insulin and blood glucose checks for two residents. On two separate occasions, a nurse performed blood glucose checks and administered insulin injections in the residents' abdomens in a commons area, where multiple residents and staff could observe the procedures. Facility policy requires that such procedures be conducted in a private area to respect residents' rights to privacy and dignity. An administrative nurse confirmed that staff are expected to take residents to a private area for these procedures.
Resident Not Included in Person-Centered Care Planning
Penalty
Summary
Facility staff failed to ensure that a resident and/or their family representative were given the opportunity to participate in the development and implementation of the resident's person-centered plan of care. Review of the facility's policy confirmed that residents and their surrogates have the right to make decisions regarding medical care and to be involved in care planning. However, medical record review showed no evidence that the resident or a family representative was invited to care conferences following admission, quarterly assessments, or after hospitalizations. An administrative nurse confirmed that care conferences are supposed to occur quarterly, after significant changes, and after hospitalizations, but documentation did not show that the resident or their representative was informed or included in these processes. As a result, the resident and/or their family representative were not afforded the opportunity to provide input or make decisions regarding changes to the resident's care, treatment, or interventions.
Failure to Timely Report Alleged Abuse and Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the administrator and to the State Survey Agency, as required by facility policy and state law. For one resident, allegations of staff being rough during care, grabbing the resident by the back of the neck, causing a bruise during a transfer, and disregarding call light requests were reported by the resident and a family member. However, an administrative nurse confirmed that these allegations were not reported to the state agency as required. Additionally, another resident with diagnoses including anxiety, stroke, dementia, and a mental disorder requiring continuous supervision was involved in a verbal altercation with another resident, during which both made threatening and abusive statements. Facility staff did not identify this incident as abusive behavior and failed to report it to the administrator or the State agency. An administrative staff member confirmed unawareness of the incident, indicating a lack of appropriate reporting and follow-up as outlined in facility policy.
Failure to Investigate and Address Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and incidents of resident-to-resident altercations. For one resident, there were reports from both the resident and a family member that staff were rough during care, including being grabbed by the back of the neck and sustaining a bruise to the hand during a transfer. The resident also reported that staff disregarded requests when responding to call lights. Although a CNA was placed on administrative leave following the abuse allegation, documentation did not include details of the allegation or the investigation process. An administrative nurse confirmed awareness of the allegations, but there was no evidence of a comprehensive investigation. Additionally, another resident with diagnoses including anxiety, stroke, dementia, and a mental disorder requiring continuous supervision was involved in a verbal altercation with another resident, during which threats and profanities were exchanged. The incident was documented in the medical record, but administrative staff were unaware of the event and no investigation was conducted. The facility did not ensure the protection of residents during the investigation process, nor did it implement or evaluate corrective actions related to these incidents.
Failure to Complete Significant Change Assessment After Resident Decline
Penalty
Summary
Facility staff failed to complete a significant change in status assessment (SCSA) for a resident who experienced a notable decline in condition. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, a SCSA is required when there is a major decline or improvement in a resident's status that affects more than one area of health and requires interdisciplinary review. In this case, the resident showed a decline in activities of daily living (ADLs), specifically requiring increased assistance with oral hygiene and taking on/off shoes and socks, as well as experiencing weight loss. Record review revealed that the resident's admission Minimum Data Set (MDS) indicated supervision was needed for oral hygiene and moderate/partial assistance for footwear. A subsequent quarterly MDS showed increased assistance was needed for both oral hygiene and footwear, along with documented weight loss. Despite these changes, there was no evidence that facility staff identified the need for or completed a SCSA following the resident's decline. An administrative staff nurse confirmed the resident's decline in these areas and the weight loss.
Failure to Notify Provider of Critically High Blood Glucose Levels
Penalty
Summary
Facility staff failed to follow professional standards of practice by not notifying the primary care provider when a resident with type 2 diabetes mellitus had blood glucose readings above the threshold specified in the physician's order. The order required staff to call the provider if blood sugar was less than 60 mg/dL or greater than 400 mg/dL. Medical record review showed that the resident had blood glucose readings of 567.0 mg/dL and 404.0 mg/dL on separate occasions, but there was no documentation that the provider was notified of these elevated levels. An administrative staff member confirmed that the physician was not notified as required by the order.
Failure to Ensure Safe Transfers and Supervision During Resident Handling
Penalty
Summary
The facility failed to provide adequate assessment and use of assistive devices necessary to prevent accidents for two residents who required assistance with transfers. In one instance, a certified nurse aide transferred a resident from bed to wheelchair and from toilet to wheelchair without using a gait belt, despite the care plan specifying its use. The resident verbalized weakness in her legs during the transfer, and the aide used manual support under the resident's arms and waist instead of the required device. In another case, two CNAs used a sit-to-stand mechanical lift to transfer a resident who was unresponsive and asleep, physically placing her hands on the assist bars. The medical record lacked documentation or assessment by a licensed nurse or therapy to confirm that this method of transfer was safe for the resident, and there was no completed sit-stand-walk data collection tool or assessment in the record. Additionally, the facility failed to provide appropriate supervision and assistance during a van transfer for a resident with multiple diagnoses, including abnormal posture, dementia, hemiparesis, and obesity. The resident's care plan required anti-tip bars on the wheelchair to be positioned upwards while going up and down the van ramp. During a transfer, the anti-rollbacks on the wheelchair caught the edge of the ramp, and the staff member was unable to hold the resident, resulting in the resident being lowered to the floor of the ramp. The staff member could not confirm if the resident hit his head, but the resident later reported possibly landing on the back of his head. The facility's failure to follow established policies and care plans regarding the use of assistive devices and proper supervision during transfers led to unsafe conditions and incidents involving residents who required assistance. The lack of proper assessment, documentation, and adherence to transfer protocols placed residents at risk of accidents and injury during both in-facility and van transfers.
Failure to Reconcile and Store Controlled Medications per Policy
Penalty
Summary
The facility failed to ensure accurate reconciliation and storage of medications for a resident during a medication pass. Specifically, a staff nurse was observed retrieving an empty morphine sulfate bottle for a resident, while the narcotic count sheet indicated that 4.25 ml of morphine sulfate should have remained in the bottle. This discrepancy was not immediately reconciled or reported as required by facility policy. Facility policy mandates that all controlled medications, including Schedule II drugs like morphine sulfate, must be verified and reconciled at each shift change. The policy requires the outgoing nurse to unlock the controlled medication storage, review the narcotic count book with the incoming nurse, and physically examine each medication for tampering or discrepancies. Any discrepancies or evidence of tampering must be reported to nursing management before the end of the shift. In this instance, the required reconciliation and reporting process was not followed.
Failure to Follow Infection Control and Perineal Care Protocols
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for two residents requiring enhanced precautions and perineal care. For one resident with an indwelling urinary catheter, the care plan required staff to use both gloves and a gown during high-contact care activities under Enhanced Barrier Precautions (EBP). However, during an observation, a certified nurse aide entered the resident's room, applied gloves but did not don a gown, and proceeded to empty the urinary drainage bag, contrary to facility policy and posted signage. Another resident, with a history of urinary tract infections and recent positive urine cultures, required staff assistance with perineal care. During observed care, a certified nursing assistant assisted the resident to the toilet and performed perineal cleaning using a washcloth, wiping from back to front, which is inconsistent with the facility's perineal care policy that specifies cleaning from front to back. Additionally, the resident was found wearing two briefs and a liner, which the CNA acknowledged was not permitted. Administrative staff confirmed that the expected infection control and perineal care procedures were not followed in both cases.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the accurate posting of daily nurse staffing information as required by its policy. On two out of four days during the survey, the posted staffing reports displayed incorrect dates: on one occasion, the report showed a date two days prior, and on another, it showed a date in the future. The facility's policy requires that staffing and resident census information be posted daily at the beginning of each shift and updated as appropriate. These discrepancies were observed during the survey and confirmed through review of the facility's policy and direct observation of the posted reports. No specific residents or staff were identified as being directly affected in the report, and no additional patient details or medical histories were provided.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 21 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 0.5 mi | — | 0 | 0 |
| Baptist Health & Rehab | 1.9 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society Augusta Place A Prospera Co | 3 mi | ★★★★★ | 2 | 0 |
| St Gabriel's Community | 3.2 mi | ★★★★★ | 1 | 0 |
| Missouri Slope | 3.6 mi | ★★★★★ | 4 | 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.