Above 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 Prairie Mission Retirement Village during CMS and state inspections, most recent first.
Multiple residents were exposed to accident hazards due to staff failing to use wheelchair footrests during transport, not providing safe transfer assistance, leaving medications and hazardous items at bedside without proper assessment, and not implementing effective fall prevention interventions. These actions and omissions resulted in unsafe conditions and increased risk of injury.
Two residents with cognitive impairments who required staff assistance for dressing were observed wearing soiled clothing in communal areas, including the dining room, without timely intervention from staff to change them into clean attire. Staff acknowledged the residents' need for assistance and the facility's policy required residents to be kept clean and treated with dignity, but these expectations were not met.
Surveyors found that the facility did not accurately complete MDS assessments for two residents, resulting in inconsistencies between documented cognitive status, mobility, and range of motion. For one resident, the MDS did not reflect her actual limitations in lower extremity ROM and dependence on staff for mobility, as confirmed by care plans, EMR, and nursing staff interviews.
A resident with severe cognitive impairment and multiple mobility-related diagnoses was repeatedly observed in uncomfortable and unsafe positions in a Broda chair, including without footrests and with inadequate support to prevent leaning. Staff interviews confirmed that positioning devices were available but not consistently used or included in the care plan, and the facility could not provide a related policy when requested.
A resident with severe cognitive impairment and high dependence for mobility developed a new stage II pressure ulcer. Although wound care and supplements were provided as ordered, staff did not notify the Registered Dietician of the new ulcer, contrary to facility policy requiring RD involvement for nutritional screening when a stage II or higher pressure ulcer develops.
A resident with end-stage renal disease, Down's syndrome, and dementia did not receive required post-dialysis assessment and monitoring after returning from hemodialysis. Staff failed to document vital signs, assess the dialysis access site, or monitor the resident's condition as required by facility policy and physician orders.
A resident with severe cognitive impairment and anxiety was administered Ativan at a higher dose than ordered on multiple occasions. The medication error occurred when a nurse gave 0.5 mg instead of the prescribed 0.25 mg, contrary to physician orders. The error was identified after the fact, and the resident did not experience adverse effects.
A resident with severe cognitive impairment and hypertension had a PRN order for clonidine to be given if systolic BP exceeded 170. The medication was never administered, and BP readings did not meet the threshold, but the order remained active for several months. Facility policy required discontinuation of unused PRN BP meds after 30 days, but this was not followed.
Failure to Prevent Accident Hazards and Ensure Safe Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. For one resident with dementia and impaired mobility, staff propelled her in a wheelchair without using footrests, causing her feet to drag on the floor during transport. Despite the facility's policy requiring footrests to be applied before pushing residents in wheelchairs, staff did not follow this protocol, and the care plan lacked specific instructions regarding the use of footrests. Interviews with staff confirmed the absence of footrests and a lack of adherence to the policy. Another resident with severe cognitive impairment and limited range of motion required substantial to maximal assistance with transfers. Staff transferred her from her wheelchair to the toilet and back without ensuring she could bear weight, resulting in her feet sliding on the tile floor. The care plan indicated the need for two staff for transfers, but the facility did not have a policy for safe transfers, and staff were uncertain about the resident's ability to bear weight during transfers. This failure to provide appropriate, safe transfers placed the resident at risk for injury. Additional deficiencies included staff pushing another resident in a Broda chair without foot pedals, causing her feet to dangle or drag on the floor, and the lack of proper positioning equipment. For a resident with depression and a history of refusing care, medications such as Vicks VapoRub and potentially hazardous items like scissors were left at the bedside without a physician's order or a self-administration assessment, contrary to facility policy. Furthermore, a resident with repeated falls and moderate cognitive impairment did not receive effective fall prevention interventions. The facility relied on a motion sensor to alert staff, but staff response was inconsistent, and the intervention did not prevent falls. The care plan and staff interviews revealed a lack of new or effective interventions to address the resident's ongoing fall risk.
Failure to Maintain Resident Dignity by Not Assisting with Clean Clothing
Penalty
Summary
Two residents with cognitive impairments were observed wearing soiled clothing in communal areas, including the dining room, without timely assistance from staff to change into clean attire. One resident with severe dementia and substantial to maximal dependence on staff for dressing was seen multiple times throughout the day wearing a shirt with dried food and liquid stains, despite staff acknowledging her need for assistance and the facility's policy requiring residents to be clean and treated with dignity. The resident's care plan and medical records confirmed her dependence on staff for dressing, yet she remained in soiled clothing among her peers for an extended period. Another resident with moderate cognitive impairment and substantial to maximum assistance needs for dressing was also observed with a dirty, stained shirt on two separate occasions. Staff interacted with her and discussed her upcoming appointment without addressing her soiled clothing until prompted by a nurse, who then ensured her shirt was changed. Interviews with staff and review of facility policy confirmed the expectation that residents should be kept clean and treated with dignity, but this standard was not upheld in these instances.
Inaccurate MDS Assessments for Residents with Mobility and Cognitive Impairments
Penalty
Summary
Surveyors identified that the facility failed to complete accurate Minimum Data Set (MDS) assessments for two residents. For one resident with diagnoses including dementia, anxiety, and weakness, discrepancies were found between the MDS, care plan, and electronic medical record (EMR) regarding her cognitive status, mobility, and range of motion (ROM). The annual MDS documented intact cognition and independence with wheelchair mobility, while the Medicare 5-Day MDS indicated moderately impaired cognition and dependence on staff for mobility. The care plan and EMR further documented an unsteady gait and limited ROM in the lower extremities, which was not accurately reflected in the MDS. Administrative nursing staff confirmed the inaccuracy of the MDS regarding the resident's ROM limitation. The facility's expectation was for MDS assessments to be completed correctly, utilizing the Resident Assessment Instrument (RAI) manual. However, the failure to accurately document the resident's limitations in the MDS resulted in an identified deficiency. The findings were based on observation, interview, and record review, and involved inconsistencies in the assessment and documentation of the resident's functional abilities and care needs.
Failure to Ensure Proper Positioning and Use of Support Devices
Penalty
Summary
A deficiency was identified when staff failed to assess and address proper positioning for a resident with multiple diagnoses, including dementia, chronic pain, neuropathy, arthritis, and low back pain. The resident had severely impaired cognition, was dependent on staff for mobility, and used a Broda chair for transport. Observations revealed the resident was left in uncomfortable and unsafe positions, such as sitting in the Broda chair without a footrest, resulting in her feet dangling or dragging on the floor, and leaning unsupported to one side. Staff interviews confirmed that positioning equipment like pillows and wedges were available but not consistently used or included in the care plan. Further review showed that the care plan noted the resident's need for assistance with mobility and the use of a Broda chair, but did not specify the use of positioning devices. Staff were observed not utilizing available foot pedals or positioning supports, and the facility was unable to provide a policy related to positioning when requested. These actions and omissions led to the failure to provide care in accordance with professional standards of practice for positioning, placing the resident at risk for increased pain and additional medical problems.
Failure to Notify RD of New Stage II Pressure Ulcer
Penalty
Summary
A resident with severe cognitive impairment and significant physical dependence developed a facility-acquired stage II pressure ulcer on her right gluteal area, proximal to the sacrum. At the time of the deficiency, the resident required substantial to maximal staff assistance for mobility and transfers, and was identified as being at risk for pressure ulcers. The resident's care plan and medical record documented the presence of the new stage II pressure ulcer, and wound care orders were implemented and followed, including cleansing, dressing changes, and administration of vitamin supplements. Despite these interventions, the facility failed to notify the Registered Dietician (RD) of the development of the new stage II pressure ulcer, as required by facility policy. Interviews with staff confirmed that the RD had not been informed of the wound, and dietary staff were unaware of the need to notify the RD when a new wound developed. The facility's policy specified that the RD should complete a nutritional screen for residents with a stage II or higher pressure ulcer, but this was not done in this case.
Failure to Provide Post-Dialysis Assessment and Care
Penalty
Summary
The facility failed to provide appropriate post-dialysis care and services to a resident with end-stage renal disease, Down's syndrome, and dementia, who required hemodialysis three times a week. Physician orders required staff to measure the resident's blood pressure on dialysis days before leaving, assess the thrill in the resident's left arm twice daily, and follow a specific diet. While staff documented pre-dialysis care such as medication administration, blood pressure, weight, and thrill assessment, there was no documentation or evidence of post-dialysis assessment or monitoring upon the resident's return from dialysis. Progress notes only indicated the resident's absence and return from dialysis, without any post-dialysis assessment or vital sign monitoring. Observations and staff interviews confirmed that after dialysis, the resident was not assessed for vital signs, access site condition, or overall well-being, contrary to facility policy, which required post-dialysis assessment, including monitoring the access site for bleeding, ensuring blood pressure stability, and documenting vital signs. Staff, including CNAs, CMAs, and nurses, reported that no specific monitoring or assessment was performed after the resident returned from dialysis, and the facility's administrative nurse was unaware that post-dialysis assessment was required. This lack of post-dialysis care and documentation constituted a deficiency in providing safe and appropriate dialysis services.
Failure to Follow Physician Orders for Antianxiety Medication Administration
Penalty
Summary
A resident with a diagnosis of anxiety and severe cognitive impairment, as indicated by low BIMS scores on both annual and quarterly assessments, was prescribed Ativan (lorazepam) 0.25 mg by mouth twice daily and 0.5 mg by mouth in the evening for anxiety. The resident's care plan noted a tendency to become anxious in the evenings and the use of antianxiety medication. Despite these physician orders, the resident was administered Ativan 0.5 mg by mouth at times when only 0.25 mg was ordered, specifically on three occasions. The medication administration error was made by a licensed nurse, who did not notice the discrepancy until after the incorrect doses had been given. The facility's policy requires medications to be administered according to physician orders, but this was not followed in this instance. Documentation showed that the resident did not experience adverse effects from the incorrect dosing, and the error was later reported to the appropriate parties.
Failure to Discontinue Unused PRN Antihypertensive Medication
Penalty
Summary
A resident with a diagnosis of hypertension and severe cognitive impairment was prescribed a PRN antihypertensive medication, clonidine, to be administered by mouth every four hours as needed for systolic blood pressure greater than 170. Review of the resident's electronic medical record showed that the PRN medication had not been administered at any time from the date it was ordered through several months of monitoring. Weekly blood pressure readings documented in the record did not show any systolic blood pressure readings above 170 during this period. Despite the lack of use and absence of clinical indication, the PRN antihypertensive medication remained active in the resident's medication orders. Facility policy required that PRN blood pressure medications not used after 30 days be discontinued unless otherwise directed by the physician. Administrative staff confirmed that the medication should have been discontinued after 30 days of non-use, but this was not done, resulting in the resident not being free from unnecessary medications.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Saint Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Parsons | 12.4 mi | ★★★★★ | 0 | 0 |
| Parsons Presbyterian Manor | 13.8 mi | ★★★★★ | 4 | 0 |
| Elmhaven East | 14.1 mi | ★★★★★ | 0 | 0 |
| Diversicare Of Chanute | 19.4 mi | ★★★★★ | 19 | 0 |
| Heritage Health Care Center | 20.4 mi | ★★★★★ | 8 | 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.