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Health Inspection Summary

Sunset Drive - A Prospera Community

1011 Boundary St NW

Mandan, ND 58554

(701) 323-1411

Deficiency Category	Inspection Date: 5/2/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 5/11/23 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 2/3/22 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	4	0	0
Quality of Life and Care Deficiencies	4	4	5
Infection Control Deficiencies	3	1	1
Resident Assessment and Care Planning Deficiencies	2	4	2
Nursing and Physician Services Deficiencies	1	0	0
Resident Rights Deficiencies	4	3	1
Nutrition and Dietary Deficiencies	1	1	0
Pharmacy Service Deficiencies	1	0	1
Environmental Deficiencies	0	0	0
Administration Deficiencies	0	0	0

Detailed result for inspection on 5/2/24

Date of last standard health inspection:	5/2/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	1/8/25Read the full report (PDF) 11/5/24Read the full report (PDF) 10/3/24Read the full report (PDF) 7/31/24Read the full report (PDF) 6/19/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	20
Average number of Health Deficiencies in North Dakota:	5.9
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	5/2/24	6/6/24	2 - Minimal harm or potential for actual harm	Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	1/8/25	2/12/25	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	1/8/25	2/12/25	2 - Minimal harm or potential for actual harm	Few
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	6/19/24	6/14/24	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	5/2/24	6/6/24	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	5/2/24	6/6/24	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	7/31/24	9/4/24	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	5/2/24	6/6/24	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	7/31/24	9/4/24	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	5/2/24	6/6/24	2 - Minimal harm or potential for actual harm	Some
Provide and implement an infection prevention and control program.	10/3/24	11/7/24	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident receives an accurate assessment.	5/2/24	6/6/24	2 - Minimal harm or potential for actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	5/2/24	6/6/24	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	7/31/24	9/4/24	2 - Minimal harm or potential for actual harm	Few

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	7/31/24	9/4/24	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	5/2/24	6/6/24	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	11/5/24	12/10/24	2 - Minimal harm or potential for actual harm	Few
Reasonably accommodate the needs and preferences of each resident.	7/31/24	9/4/24	2 - Minimal harm or potential for actual harm	Some

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	5/2/24	6/6/24	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	5/2/24	6/6/24	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 5/11/23

Date of last standard health inspection:	5/11/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	9/27/23Read the full report (PDF) 5/11/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	13
Average number of Health Deficiencies in North Dakota:	5
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Few
Provide safe and appropriate respiratory care for a resident when needed.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Few
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident receives an accurate assessment.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Some
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	9/27/23	11/1/23	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Some

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 2/3/22

Date of last standard health inspection:	2/3/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	3/9/23Read the full report (PDF) 9/26/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	10
Average number of Health Deficiencies in North Dakota:	6.3
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	9/26/22	11/4/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/26/22	11/4/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	3/9/23	4/21/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	2/3/22	3/10/22	3 - Actual harm	Few
Provide care and assistance to perform activities of daily living for any resident who is unable.	2/3/22	3/10/22	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	2/3/22	3/10/22	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure services provided by the nursing facility meet professional standards of quality.	3/9/23	4/21/23	2 - Minimal harm or potential for actual harm	Few
Assess the resident when there is a significant change in condition	2/3/22	3/10/22	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	3/9/23	4/21/23	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	2/3/22	3/10/22	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	1/8/25	2/12/25	2 - Minimal harm or potential for actual harm	Few
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	1/8/25	2/12/25	2 - Minimal harm or potential for actual harm	Few
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.	6/19/24	6/14/24	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	7/31/24	9/4/24	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	7/31/24	9/4/24	2 - Minimal harm or potential for actual harm	Few
Provide and implement an infection prevention and control program.	10/3/24	11/7/24	2 - Minimal harm or potential for actual harm	Few
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	7/31/24	9/4/24	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	7/31/24	9/4/24	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	11/5/24	12/10/24	2 - Minimal harm or potential for actual harm	Few
Reasonably accommodate the needs and preferences of each resident.	7/31/24	9/4/24	2 - Minimal harm or potential for actual harm	Some
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	9/27/23	11/1/23	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	5/11/23	6/15/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate pressure ulcer care and prevent new ulcers from developing.	9/26/22	11/4/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/26/22	11/4/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	3/9/23	4/21/23	2 - Minimal harm or potential for actual harm	Few
Ensure services provided by the nursing facility meet professional standards of quality.	3/9/23	4/21/23	2 - Minimal harm or potential for actual harm	Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	3/9/23	4/21/23	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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