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
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
0.98
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.66
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
5.47
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.98
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.23
CMS adjusted RN staffing hours
Adjusted total hours
6.85
CMS adjusted total nurse staffing hours
Case-mix index
1.09
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
35%
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 13 · 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 10 · 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 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · 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 | 28.36% |
8.2%
20.2 pts better
|
Numerator 19 · Denominator 67 |
| Staff flu vaccination coverage | 85.07% |
42%
43.1 pts better
|
Numerator 57 · Denominator 67 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · 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 | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.6 · Expected 1.1 · Used in QM five-star |
| 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 · Adjusted 0.4 · Observed 0.3 · 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · 4Q avg 100.0% |
| 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 | 3.6% |
4.4%
0.8 pts better
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.5% · Q3 5.0% · 4Q avg 3.6% · 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 · Q1 0.0% · 4Q avg 0.0% |
| 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 · Q1 14.3% · 4Q avg 7.2% |
| 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 · Q1 23.8% · 4Q avg 13.0% |
| 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 · Q1 25.0% · 4Q avg 29.2% · 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% · 4Q avg 0.0% |
| 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 · 4Q avg 26.8% · Used in QM five-star |
| 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 · Q1 25.0% · 4Q avg 31.2% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 4.3% · Q2 0.0% · Q3 10.0% · 4Q avg 6.0% · Used in QM five-star |
| 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 · Q1 20.5% · Q2 17.9% · 4Q avg 28.9% |
| 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 · Q1 0.0% · Q2 16.3% · Q3 10.3% · 4Q avg 7.9% · Used in QM five-star |
| 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 · 4Q avg 68.2% |
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
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