Cycle 1
Health 2025-03-13 · Fire 2025-03-13
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Saint Paul, KS
Prairie Mission Retirement Village
3-star overall rating with 4-star inspections with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
242 Carroll Street, Saint Paul, KS
(620) 449-2400
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
61
Certified beds
Average residents
27
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.24
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.25
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.70
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
1.25
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.47
CMS adjusted RN staffing hours
Adjusted total hours
4.90
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
941
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.91
Composite VBP score used to determine payment impact.
Payment multiplier
1.0169
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
7.72
Baseline 51.16% · Performance 32.14% · Measure score 7.72 · Achievement 7.72 · Improvement 6.73
Adjusted total nurse staffing
4.67
Baseline 4.91 hours · Performance 4.41 hours · Measure score 4.67 · Achievement 4.67 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.09% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 5.76% |
| Discharge to community | 34.85% |
50.57%
15.7 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 25.71% · Lower 95% interval 25.6% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 16 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.03% |
8.2%
5.2 pts worse
|
Numerator 2 · Denominator 66 |
| Staff flu vaccination coverage | 22.54% |
42%
19.5 pts worse
|
Numerator 16 · Denominator 71 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.8
0.6 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.2
0.2 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
91.8%
5.3 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 87.5% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
4.4%
0.5 pts better
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 3.7% · Q3 4.2% · Q4 0.0% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
5.6%
0.5 pts worse
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 8.0% · Q3 8.7% · Q4 4.2% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 13.4% |
5.0%
8.4 pts worse
|
5.4%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 20.0% · Q3 15.0% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
23.2%
7.9 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 18.2% · Q3 14.3% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.0% |
19.8%
15.2 pts worse
|
16.7%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.0% · 4Q avg 35.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 32.1% |
18.4%
13.7 pts worse
|
16.3%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.1% |
18.8%
5.3 pts worse
|
14.9%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 23.8% · Q3 25.0% · 4Q avg 24.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
1.8%
0.9 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 4.4% · Q4 3.2% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
3.1%
1.1 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.0% · Q3 0.0% · Q4 4.2% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.6% |
23.2%
0.6 pts better
|
19.8%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 31.1% · Q3 25.3% · Q4 15.3% · 4Q avg 22.6% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.6%
2.5 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.6% · Q4 3.4% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.0% |
75.6%
7.4 pts better
|
81.7%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 83.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-21 · Fire 2023-06-21
4 health deficiencies
Top issue: Infection Control (1 deficiency)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-01-26 · Fire 2022-01-26
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-08-15
F · Potential for more than minimal harm
2025-07-16
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-08-15
F · Potential for more than minimal harm
2025-07-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-15
F · Potential for more than minimal harm
2025-03-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-12
F · Potential for more than minimal harm
2025-03-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-12
F · Potential for more than minimal harm
2025-03-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-12
E · Potential for more than minimal harm
2025-03-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-03-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-12
D · Potential for more than minimal harm
2025-03-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-05-12
F · Potential for more than minimal harm
2023-06-21
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-08-12
F · Potential for more than minimal harm
2023-06-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-12
F · Potential for more than minimal harm
2023-06-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-12
F · Potential for more than minimal harm
2023-06-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-12
F · Potential for more than minimal harm
2023-06-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-12
F · Potential for more than minimal harm
2023-06-21
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-08-12
F · Potential for more than minimal harm
2023-06-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-12
F · Potential for more than minimal harm
2023-06-21
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-08-12
E · Potential for more than minimal harm
2023-06-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-12
E · Potential for more than minimal harm
2023-06-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-12
E · Potential for more than minimal harm
2023-06-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-12
E · Potential for more than minimal harm
2023-06-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-12
F · Potential for more than minimal harm
2022-01-26
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2022-03-16
F · Potential for more than minimal harm
2022-01-26
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-03-16
F · Potential for more than minimal harm
2022-01-26
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2022-03-16
F · Potential for more than minimal harm
2022-01-26
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-03-16
F · Potential for more than minimal harm
2022-01-26
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-03-16
F · Potential for more than minimal harm
2022-01-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-03-16
F · Potential for more than minimal harm
2022-01-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-03-16
F · Potential for more than minimal harm
2022-01-26
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-03-16
F · Potential for more than minimal harm
2022-01-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-16
E · Potential for more than minimal harm
2022-01-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-03-16
E · Potential for more than minimal harm
2022-01-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-03-16
E · Potential for more than minimal harm
2022-01-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-13
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-14
F · Potential for more than minimal harm
2023-06-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-21
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-20
F · Potential for more than minimal harm
2022-01-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-25
F · Potential for more than minimal harm
2022-01-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-02-25
D · Potential for more than minimal harm
2022-01-26
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-02-25
Penalties and ownership
What sits behind the stars
Ownership
Bookout, Logan
Operational/Managerial Control · Individual
Bookout, Logan
Corporate Officer · Individual
Carter, Chris
Corporate Director · Individual
Carter, Michael
Corporate Director · Individual
Ewan, Melinda
Operational/Managerial Control · Individual
Ewan, Melinda
Corporate Officer · Individual
Smith, Keith
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Good Samaritan Society - Parsons
Parsons, KS
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Parsons Presbyterian Manor
Parsons, KS
3-star overall rating with 3-star inspections with $14,433 in total fines with 6 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#3
Elmhaven East
Parsons, KS
2-star overall rating with 2-star inspections with $53,504 in total fines with 12 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Jump out