Cycle 1
Health 2025-03-31 · Fire 2025-03-31
6 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
14 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Wichita, KS
Mount St Mary
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
3700 E Lincoln St, Wichita, KS
(316) 686-7171
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
24
Certified beds
Average residents
20
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2018-03-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.98
Registered nurse staffing
LPN hours / resident day
0.83
Licensed practical nurse staffing
Aide hours / resident day
3.66
Nurse aide staffing
Weekend hours
4.98
Weekend nurse staffing
RN turnover
40%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
2.2
1.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 | 3.6% |
4.4%
0.8 pts better
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents who lose too much weight | 7.2% |
5.0%
2.2 pts worse
|
5.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.0% |
23.2%
10.2 pts better
|
19.6%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 29.2% |
19.8%
9.4 pts worse
|
16.7%
12.5 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 | 26.8% |
18.4%
8.4 pts worse
|
16.3%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.2% |
18.8%
12.4 pts worse
|
14.9%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 6.0% |
3.1%
2.9 pts worse
|
1.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.9% |
23.2%
5.7 pts worse
|
19.8%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
4.6%
3.3 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.2% |
75.6%
7.4 pts worse
|
81.7%
13.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-04 · Fire 2023-10-04
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-01-20 · Fire 2022-01-20
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-31
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-03-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-06
F · Potential for more than minimal harm
2023-10-04
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 2023-12-01
D · Potential for more than minimal harm
2023-10-04
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-10-04
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-12-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-31
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-31
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-31
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-31
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 2025-04-23
C · Minimal harm
2025-03-31
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-23
F · Potential for more than minimal harm
2023-10-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-10-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-04
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-04
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-04
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 2023-11-03
D · Potential for more than minimal harm
2023-10-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-10-04
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-11-03
Penalties and ownership
What sits behind the stars
Ownership
Congregation Of The Sisters Of St Joseph Inc
5% Or Greater Direct Ownership Interest · Organization
Bergen, Patricia
Corporate Director · Individual
Bergen, Patricia
Corporate Officer · Individual
Bise, David
Operational/Managerial Control · Individual
Bise, David
Corporate Officer · Individual
Bise, David
Contracted Managing Employee · Individual
Conway, Nancy
Corporate Director · Individual
Conway, Nancy
Corporate Officer · Individual
Csj Initiatives Inc
Operational/Managerial Control · Organization
Kreyenbuhl, Joan
Corporate Director · Individual
Kreyenbuhl, Joan
Corporate Officer · Individual
O'brien, Marguerite
Corporate Director · Individual
O'brien, Marguerite
Corporate Officer · Individual
Parks, Christine
Corporate Director · Individual
Parks, Christine
Corporate Officer · Individual
Quick, Michael
Corporate Director · Individual
Schab, Tami
Corporate Director · Individual
Slater, William
Operational/Managerial Control · Individual
Teichman, Rita Ann
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Lincoln Care And Rehab
Wichita, KS
1-star overall rating with 1-star inspections with $39,880 in total fines with 28 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
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
#3
Medicalodges Wichita
Wichita, KS
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
Jump out