Mount St Mary
3700 E Lincoln St, Wichita, KS 67218 · Sedgwick County · 24 certified beds · avg 21 residents/day · certified since Mar 28, 2018
Part of chain: CSJ INITIATIVES (2 facilities, chain avg rating 4.5★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (14)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 31, 2025 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Mar 31, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Mar 31, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Mar 31, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Mar 31, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint |
| Mar 31, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint |
| Oct 4, 2023 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 4, 2023 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Oct 4, 2023 | D · Potential for harm, one-off | The facility did not observe each nurse aide's job performance or provide regular training as required. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (8 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 8 | 0 | F |
| 2025 | 6 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Kansas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 6.05 | 4.58 | 3.95 | top 11% in Kansas; top 4% in the U.S. |
| Registered Nurse hours | 1.13 | 0.81 | 0.69 | top 17% in Kansas; top 11% in the U.S. |
| Weekend total nurse staffing | 5.55 | 4.05 | 3.50 | top 9% in Kansas; top 3% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.64 | 0.49 | 0.48 | top 24% in Kansas; top 20% in the U.S. |
| Total nursing staff turnover (%) | 31.0 | 48.1 | 45.8 | top 11% in Kansas; top 16% in the U.S. |
| RN turnover (%) | 33.3 | 42.0 | 42.9 | top 34% in Kansas; top 33% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.08, RN 0.95, weekend 4.66. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Congregation of the Sisters of St Joseph INC | Organization | 5% or Greater Direct Ownership Interest | 100% | 12/01/2017 |
| Bergen, Patricia | Individual | Corporate Director | NOT APPLICABLE | 07/04/2014 |
| Bergen, Patricia | Individual | Corporate Officer | NOT APPLICABLE | 07/04/2014 |
| Bise, David | Individual | Contracted Managing Employee | NOT APPLICABLE | 12/01/2017 |
| Bise, David | Individual | Corporate Officer | NOT APPLICABLE | 03/28/2018 |
| Bise, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2017 |
| Conway, Nancy | Individual | Corporate Director | NOT APPLICABLE | 07/04/2014 |
| Conway, Nancy | Individual | Corporate Officer | NOT APPLICABLE | 07/04/2014 |
| CSJ Initiatives INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2017 |
| Kreyenbuhl, Joan | Individual | Corporate Director | NOT APPLICABLE | 07/09/2014 |
| Kreyenbuhl, Joan | Individual | Corporate Officer | NOT APPLICABLE | 07/09/2014 |
| O'Brien, Marguerite | Individual | Corporate Director | NOT APPLICABLE | 07/04/2014 |
| O'Brien, Marguerite | Individual | Corporate Officer | NOT APPLICABLE | 12/15/2017 |
| Parks, Christine | Individual | Corporate Director | NOT APPLICABLE | 07/09/2014 |
| Parks, Christine | Individual | Corporate Officer | NOT APPLICABLE | 07/09/2014 |
| Quick, Michael | Individual | Corporate Director | NOT APPLICABLE | 07/01/2017 |
| Schab, Tami | Individual | Corporate Director | NOT APPLICABLE | 07/01/2017 |
| Slater, William | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/28/2018 |
| Teichman, Rita Ann | Individual | Corporate Director | NOT APPLICABLE | 12/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How often do you evaluate your nurse aides and what ongoing training do they receive?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Lincoln Care and Rehab | 0.3 mi | Wichita, KS | ★☆☆☆☆ | 1/5 | |
| Orchard Gardens | 1.8 mi | Wichita, KS | ★☆☆☆☆ | 1/5 | |
| Medicalodges Wichita | 1.8 mi | Wichita, KS | ★★★☆☆ | 3/5 | |
| Life Care Center of Wichita | 2.0 mi | Wichita, KS | ★★★★☆ | 3/5 | |
| Horizon Post Acute | 3.6 mi | Wichita, KS | ★☆☆☆☆ | 1/5 | |
| Homestead Health Center | 3.7 mi | Wichita, KS | ★★☆☆☆ | 2/5 | |
| Great Plains Post Acute | 4.1 mi | Wichita, KS | ★☆☆☆☆ | 1/5 | |
| Ascension Living via Christi Village McLean | 4.7 mi | Wichita, KS | ★★★★★ | 4/5 | |
| Larksfield Place | 4.8 mi | Wichita, KS | ★★★★★ | 4/5 | |
| Center at Waterfront LLC | 4.8 mi | Wichita, KS | ★★★☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 175561.