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
Staffing
Hours and turnover
RN hours / resident day
1.24
Registered nurse staffing
LPN hours / resident day
0.25
Licensed practical nurse staffing
Aide hours / resident day
2.64
Nurse aide staffing
Weekend hours
3.70
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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#2
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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
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