Mount St. Mary
3700 E Lincoln St., Wichita, KS 67218 · Sedgwick County · (316) 686-7171
24 certified beds, about 21 residents a day · Non profit - Corporation · Medicare and Medicaid since 2018
CMS high performing icon Part of a continuing care retirement community Certified for Medicaid Certified for Medicare
Overall
5 of 5
Health inspections
4 of 5
Staffing
5 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 175561 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on March 31, 2025, inspectors cited 6 health deficiencies (the Kansas average is 9.5, the national average 9.2).
None of its 14 health citations since January 2022 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 5.08 hours per resident per day, against 4.07 across Kansas and 3.86 nationally. Registered nurses accounted for 0.95 of those hours.
31.0% of nursing staff left within the year CMS measured (Kansas average 48.1%).
CMS links it to Csj Initiatives, an affiliated group of 2 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
001/22
810/23
603/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
1E
2F
Potential for minimal harm
0A
0B
1C
March 31, 2025Standard inspection, Complaint inspection · 6 citations
- F Observe each nurse aide's job performance and give regular training.
Inspectors wroteThe facility reported a census of 22 residents. Based on interviews and record review, the facility failed to complete an annual performance review at least once every 12 months for Certified Nurse Aide (CNA) M and Certified Medication Aides (CMA) S and CMA T. This placed the residents at risk for decreased quality of care.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteThe facility reported a census of 22 residents with 15 residents sampled. Based on interviews and record review, the facility failed to complete a thorough baseline care plan for Resident (R) 17 regarding the use of a non-invasive ventilator (a mechanical ventilation technique that delivers oxygen through a face mask without the use of endotracheal (in the throat) intubation). This placed the resident at risk for respiratory complications due to uncommunicated care needs
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteThe facility reported a census of 22 residents with 15 residents sampled, including one resident reviewed for respiratory care. Based on observation, record review, and interview, the facility failed to obtain a physician's order for the use of a non-invasive ventilator (a mechanical ventilation technique that delivers oxygen through a face mask without the use of endotracheal (in the throat) intubation) for Resident (R) 17. This placed R17 at risk for respiratory complications.
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteThe facility reported a census of 22 residents with 15 residents sampled, including two residents reviewed for pain. Based on interview and record review, the facility failed to offer non-pharmaceutical interventions for pain for Resident (R)18, who had chronic pain (pain that lasts longer than three months). This placed R18 at risk for untreated pain.
- D 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.
Inspectors wroteThe facility reported a census of 22 residents with 15 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 12 was free from unnecessary medications when staff failed to assess R12 for signs of tardive dyskinesia (TD-an abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs, and trunk) at least every six months per the standard of care. This placed the resident at risk for adverse effects of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication.
- C Post nurse staffing information every day.
Inspectors wroteThe facility reported a census of 22 residents. Based on record review and interviews, the facility failed to display accurate, publicly accessible, and identifiable staffing information on a daily basis for the 22 residents who reside in the facility.
October 4, 2023Standard inspection · 8 citations
- F Provide and implement an infection prevention and control program.
Inspectors wroteThe facility reported a census of 23 residents. Based on interview and record review, the facility failed to ensure ongoing infection surveillance to determine risks of infections to the residents of the facility.
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteThe facility reported a census of 23 residents with 14 residents sampled. Based on observation, interview, and record review, the facility failed to complete a comprehensive care plan for three Residents (R)11, R 15 and R 10, regarding lack of foot pedals on their wheelchairs and R 15, R 4 and R 6, regarding the antipsychotic (used to treat psychosis--any major mental disorder characterized by a gross impairment in reality testing) medication.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteThe facility reported a census of 23 residents with 14 selected for review. Based on interview and record review, the facility failed to accurately assess one Resident (R)21's use of antipsychotic (a class of medications used to treat psychotic disorders) medication for the Minimum Data Set (MDS), as required.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteThe facility reported a census of 23 residents with 14 residents sampled. Based on interview and record review, the facility failed to review and revise the care plan for one Resident (R)11, regarding new interventions following three non-injury falls.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteThe facility reported a census of 23 residents with 14 selected for review which included three residents selected for Activities of Daily Living (ADL). Based on observation, interview, and record review, the facility failed to provide personal grooming to one Resident (R)14, of the three residents reviewed for ADL.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteThe facility reported a census of 23 residents with 14 residents sampled including three residents sampled for accidents. Based on observation, interview, and record review, the facility failed to provide safe transport for two Residents (R)11 and R 10 and R 15, regarding lack of foot pedals on the resident's wheelchairs and failed to implement interventions following three non-injury falls for one R15.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteThe facility reported a census of 23 residents with 14 selected for review which included two residents reviewed for urinary incontinence. Based on observation, interview, and record review, the facility failed to ensure voiding assessment and timely incontinence care for one Resident (R)14, of the two residents reviewed for urinary incontinence.
- D Observe each nurse aide's job performance and give regular training.
Inspectors wroteThe facility reported a census of 23 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for one of five Certified Nurse Aides (CNA) reviewed, CNA P, to ensure adequate appropriate cares and services provided to the residents of the facility.
January 20, 2022Standard inspection · 0 citations
Fire safety inspections
18 fire safety citations on file: 14 on March 31, 2025, 4 on October 4, 2023.
Every fire safety citation18 citations
- F Include a process for Emergency Preparedness collaboration.
- F Address subsistence needs for staff and patients.
- F Establish policies and procedures for medical documentation.
- F Establish methods for sharing information.
- F Provide a means of sharing information on occupancy/needs.
- F Provide family notifications of emergency plan.
- F Keep aisles, corridors, and exits free of obstruction in case of emergency.
- F Provide properly protected cooking facilities.
- F Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- F Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- F Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- F Install corridor and hallway doors that block smoke.
- F Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F Have simulated fire drills held at unexpected times.
- F Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
- D Inspect, test, and maintain automatic sprinkler systems.
- D Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Kansas | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.08 | 4.07 | 3.86 |
| Registered nurses | 0.95 | 0.71 | 0.69 |
| All nursing staff on weekends | 4.66 | 3.60 | 3.42 |
| Nurse aides | 3.41 | ||
| Licensed practical nurses | 0.71 | ||
| Nursing staff turnover (share who left in a year) | 31.0% | 48.1% | 45.8% |
| Registered nurse turnover | 33.3% | 42.0% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.22 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 5.25 on weekdays and 4.66 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 18.9% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 5.39 in April to June 2025 to 5.08 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.08 | 0.95 | 5.25 | 4.66 | 18.9% | 0 of 90 | 21 |
| Oct to Dec 2025 | 5.44 | 1.02 | 5.66 | 4.88 | 25.6% | 0 of 92 | 20 |
| Jul to Sep 2025 | 5.47 | 0.98 | 5.66 | 4.98 | 19.7% | 0 of 92 | 20 |
| Apr to Jun 2025 | 5.39 | 0.98 | 5.68 | 4.64 | 5.0% | 0 of 91 | 21 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Kansas, Jan to Mar 2026 | 4.01 | 0.67 | 4.19 | 3.56 | 4.8% | 0.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Kansas | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 22.2 | 17.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.6 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 10.4 | 2.9 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.3 | 4.3 | 3.2 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 24.3 | 16.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.8 | 4.4 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 28.6 | 18.1 | 15.4 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 1.8 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.4 | 2.1 | 1.8 |
Owners and operators
Legal business name: MOUNT ST MARY INC. CMS links this home to Csj Initiatives, a group of 2 nursing homes averaging 4.5 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Congregation of the Sisters of St. Joseph Inc | 5% or greater direct ownership interest | Organization | 100% | 12/01/2017 |
| Bise, David | Contracted managing employee | Individual | 12/01/2017 | |
| Bergen, Patricia | Corporate director | Individual | 07/04/2014 | |
| Conway, Nancy | Corporate director | Individual | 07/04/2014 | |
| Kreyenbuhl, Joan | Corporate director | Individual | 07/09/2014 | |
| O'Brien, Marguerite | Corporate director | Individual | 07/04/2014 | |
| Parks, Christine | Corporate director | Individual | 07/09/2014 | |
| Quick, Michael | Corporate director | Individual | 07/01/2017 | |
| Schab, Tami | Corporate director | Individual | 07/01/2017 | |
| Teichman, Rita Ann | Corporate director | Individual | 12/01/2017 | |
| Bergen, Patricia | Corporate officer | Individual | 07/04/2014 | |
| Bise, David | Corporate officer | Individual | 03/28/2018 | |
| Conway, Nancy | Corporate officer | Individual | 07/04/2014 | |
| Kreyenbuhl, Joan | Corporate officer | Individual | 07/09/2014 | |
| O'Brien, Marguerite | Corporate officer | Individual | 12/15/2017 | |
| Parks, Christine | Corporate officer | Individual | 07/09/2014 | |
| Csj Initiatives Inc | Operational/managerial control | Organization | 12/01/2017 | |
| Bise, David | Operational/managerial control | Individual | 12/01/2017 | |
| Slater, William | Operational/managerial control | Individual | 03/28/2018 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 5 problems in this area, most recently on March 31, 2025: "Provide safe and appropriate respiratory care for a resident when needed."
- When is the care plan meeting, and can family attend it?Inspectors cited 4 problems in this area, most recently on March 31, 2025: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
- How many nurses and aides work each shift, nights and weekends included?Inspectors cited 3 problems in this area, most recently on March 31, 2025: "Observe each nurse aide's job performance and give regular training."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 1 problem in this area, most recently on March 31, 2025: "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."
Other nursing homes nearby
- Lincoln Care and Rehab Wichita, 0.3 mi · 1 of 5 stars · 43 citations
- Advena Living on Woodlawn Wichita, 1.8 mi · 1 of 5 stars · 50 citations
- Medicalodges Wichita Wichita, 1.8 mi · 3 of 5 stars · 19 citations
- Life Care Center of Wichita Wichita, 2 mi · 4 of 5 stars · 15 citations
- Horizon Post Acute Wichita, 3.6 mi · 1 of 5 stars · 63 citations
- Homestead Health Center Wichita, 3.7 mi · 2 of 5 stars · 22 citations
- Great Plains Post Acute Wichita, 4.1 mi · 1 of 5 stars · 62 citations
- Ascension Living Via Christi Village McLean Wichita, 4.7 mi · 5 of 5 stars · 14 citations
Common questions
- What is Mount St. Mary's Medicare star rating?
- CMS rates Mount St. Mary 5 out of 5 stars overall, with 4 for health inspections, 5 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Mount St. Mary get at its last inspection?
- 6 health deficiencies at the standard inspection on March 31, 2025. The Kansas average is 9.5.
- Has Mount St. Mary been fined?
- CMS lists no fines in the last three years.
- Does Mount St. Mary accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Mount St. Mary?
- CMS lists 19 owners and managers, and links the home to Csj Initiatives. Legal business name: MOUNT ST MARY INC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.