01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-31 | 6 | 2025-03-31 | 14 |
| Cycle 2 | 2023-10-04 | 8 | 2023-10-04 | 4 |
| Cycle 3 | 2022-01-20 | 0 | 2022-01-20 | 0 |
CMS CCN 1755612026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Mount St Mary
3700 E Lincoln St · Wichita, KS 67218 · Sedgwick County
Certified beds24CMS provider file
Recent citation rows32current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
32 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-03-31 · FIREE0009Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Include a process for Emergency Preparedness collaboration.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · FIREE0015Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · FIREE0023Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures for medical documentation.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · FIREE0033Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish methods for sharing information.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · FIREE0034Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Provide a means of sharing information on occupancy/needs.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · FIREE0035Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Provide family notifications of emergency plan.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-04-23 · complaint2025-03-31 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-04-23 · complaint2025-03-31 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2025-04-23 · complaint2025-03-31 · HEALTHF0730Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2025-04-23 · complaint2025-03-31 · HEALTHF0732Severity C · widespread; potential for minimal harm
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Correction field: Deficient, Provider has date of correction · 2025-04-23 · complaint2025-03-31 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-04-23 · complaint2025-03-31 · FIREK0211Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · FIREK0324Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · FIREK0346Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · FIREK0354Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · FIREK0362Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · FIREK0363Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2025-06-062025-03-31 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2025-06-062023-10-04 · HEALTHF0641Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Correction field: Deficient, Provider has date of correction · 2023-11-032023-10-04 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-11-032023-10-04 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2023-11-032023-10-04 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2023-11-0303 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CONGREGATION OF THE SISTERS OF ST JOSEPH INCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 12/01/2017
- BISE, DAVIDIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 12/01/2017
- BERGEN, PATRICIAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/04/2014
- CONWAY, NANCYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/04/2014
- KREYENBUHL, JOANIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/09/2014
- O'BRIEN, MARGUERITEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/04/2014
- PARKS, CHRISTINEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/09/2014
- QUICK, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2017
- SCHAB, TAMIIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2017
- TEICHMAN, RITA ANNIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 12/01/2017
- BERGEN, PATRICIAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/04/2014
- BISE, DAVIDIndividual · CORPORATE OFFICERNOT APPLICABLE · since 03/28/2018
- CONWAY, NANCYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/04/2014
- KREYENBUHL, JOANIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/09/2014
- O'BRIEN, MARGUERITEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/15/2017
- PARKS, CHRISTINEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/09/2014
- CSJ INITIATIVES INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2017
- BISE, DAVIDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2017
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours5.08per resident day
RN hours0.95per resident day
Weekend nurse hours4.66per resident day
Staff turnover31.0%CMS reported field
06 / LOCAL RECORDS
Open the Wichita ledger →Other published facilities nearby
Ascension Living Via Christi Village Mclean36 beds · CMS overall 5/520 citation rowsAvita Health And Rehab At Reeds Cove76 beds · CMS overall 3/557 citation rowsAzria Health Wichita70 beds · CMS overall 3/573 citation rowsCaritas Center, Inc22 beds · CMS overall 5/536 citation rowsCenter At Waterfront Llc80 beds · CMS overall 3/547 citation rowsFamily Health & Rehabilitation Center72 beds · CMS overall 4/544 citation rowsGreat Plains Post Acute118 beds · CMS overall 1/587 citation rowsHomestead Health Center45 beds · CMS overall 2/550 citation rows