Cycle 1
Health 2024-04-24 · Fire 2024-04-24
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Wichita, KS
Caritas Center, Inc
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1400 S Sheriden St, Wichita, KS
(316) 942-2201
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
22
Certified beds
Average residents
18
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-04-04
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
1.07
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.35
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.89
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
6.31
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
2.42
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.95
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.53
CMS adjusted RN staffing hours
Adjusted total hours
9.01
CMS adjusted total nurse staffing hours
Case-mix index
0.96
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
21%
Annual nurse turnover · state 50% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 4 · 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 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.64% |
8.2%
4.6 pts worse
|
Numerator 2 · Denominator 55 |
| Staff flu vaccination coverage | 12.5% |
42%
29.5 pts worse
|
Numerator 8 · Denominator 64 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · 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 | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.2 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 12.1% |
4.4%
7.7 pts worse
|
3.3%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
5.0%
3.2 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.6% |
23.2%
7.6 pts better
|
19.6%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.0% |
19.8%
2.2 pts worse
|
16.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.5% |
18.4%
11.9 pts better
|
16.3%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.8% |
18.8%
4 pts better
|
14.9%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.3% |
3.1%
3.2 pts worse
|
1.7%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.1% |
23.2%
15.1 pts better
|
19.8%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.1% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.6%
4.6 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-04 · Fire 2022-08-04
0 health deficiencies
No concentrated health issue counts in this cycle.
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2021-04-22 · Fire 2021-04-22
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-24
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-24
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2024-05-30
F · Potential for more than minimal harm
2024-04-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-03
E · Potential for more than minimal harm
2024-04-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-03
F · Potential for more than minimal harm
2022-08-04
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-08-04
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-08-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-08-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-08-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-08-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-08-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-11-10
F · Potential for more than minimal harm
2022-08-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-10
E · Potential for more than minimal harm
2022-08-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-10
F · Potential for more than minimal harm
2021-04-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-06-15
F · Potential for more than minimal harm
2021-04-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-06-15
F · Potential for more than minimal harm
2021-04-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-06-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-04-24
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 2024-05-17
D · Potential for more than minimal harm
2024-04-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-24
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 2024-05-17
D · Potential for more than minimal harm
2024-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-24
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-05-17
D · Potential for more than minimal harm
2021-04-22
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-05-11
D · Potential for more than minimal harm
2021-04-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-05-11
D · Potential for more than minimal harm
2021-04-22
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-05-11
D · Potential for more than minimal harm
2021-04-22
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 2021-05-11
Penalties and ownership
What sits behind the stars
Ownership
Adorers Of The Blood Of Christ United States Region
5% Or Greater Direct Ownership Interest · Organization
Adorers Of The Blood Of Christ United States Region
5% Or Greater Mortgage Interest · Organization
Bergkamp, Victoria
Corporate Officer · Individual
Clark, Mary
Corporate Officer · Individual
Csj Initiatives Inc
Operational/Managerial Control · Organization
Hughes, Mary
Corporate Director · Individual
Johnson, Joshua
Corporate Officer · Individual
Laquet, Angela
Corporate Director · Individual
Mccann, Janet
Corporate Director · Individual
Roughton, Susan
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Orchard Gardens
Wichita, KS
1-star overall rating with 1-star inspections with $24,908 in total fines with 20 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
#2
Regent Park Rehabilitation And Healthcare
Wichita, KS
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Center At Waterfront LLC
Wichita, KS
3-star overall rating with 2-star inspections with $12,740 in total fines with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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