Mount St Mary
3700 E Lincoln St, Wichita, KS 67218 · Non profit - Corporation · 24 certified beds · (316) 686-7171 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 22.2% | 17.9% | 15.4% | worse |
| Long-stay residents who lose too much weight | 6.6% | 4.9% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 1.6% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 10.4% | 2.9% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.0% | 6.5% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.3% | 4.3% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 24.3% | 16.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 8.2% | 23.2% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 95.5% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.8% | 4.4% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 36.3% | 22.6% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.6% | 18.1% | 17.1% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.42 | 1.80 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.43 | 2.13 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Staffing
How full it usually is: this home is certified for 24 beds and averages 20.8 residents a day — about 87% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.95 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.41 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.66 hrs/resident/day on weekends vs 5.25 on weekdays — 11% thinner on weekends. RN hours go from 1.08 to 0.64 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
14 citations, most serious first — scroll within the box to see all.
- Potential for harm · Fcited before2025-03-31 · tag F0730 — widespreadObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
The 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. Findings included: - A review of five employee personnel files, employed by the facility for greater than one year, revealed the following concerns: CNA M, hired on 10/11/23, lacked an annual performance review in her personnel file. CMA S, hired on 12/21/23, lacked an annual performance review in his personnel file. CMA T hired on 1/18/23, lacked an annual performance review in her personnel file. On 03/27/25 at 11:03 AM, Administrative Nurse D stated CNA evaluations were to be done annually. Administrative Nurse D confirmed the three staff members (listed above) lacked an annual evaluation. The facility policy for Evaluation Process, revised 01/02/25, included the Center shall review the work performance of employees with a formal written evaluation annually.
- Potential for harm · Dcited before2025-03-31 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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 Findings included: - A review of R17's electronic medical record (EMR) revealed a diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She utilized a non-invasive mechanical ventilator. The Functional Abilities Care Area Assessment (CAA), dated 01/20/25,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-31 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - R17's electronic medical record (EMR) revealed a diagnosis of chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. She utilized a non-invasive mechanical ventilator. The Functional Abilities Care Area Assessment (CAA) dated 01/20/25…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-31 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - A review of R18's electronic medical record (EMR) revealed a diagnosis of chronic pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of five, indicating severe cognitive impairment. She received scheduled and as-needed (PRN) pain medications and had no non-pharmacological interventions for pain. The Pain Care Area Assessment (CAA), dated 11/19/24, documented the resident had chronic pain and required PRN pain medication. The Quarterly MDS, dated 02/19/25, documented the resident had a BIMS score of five, indicating severe cognitive impairment. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-31 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement 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.
What the surveyor found here — an excerpt from the official record, may be distressing
The 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. Findings included: - R12s Electronic Health Record (EHR) revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dementia (progressive mental disorder characterized by failing memory, confusion) with other behavioral disturbances. The 02/11/25 Minimum Data Set (MDS) documented a Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-10-04 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
The 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. Findings included: - Review of the Infection Control Monthly Logbook, revealed lack of September 2023 log for infections. Interview on 10/04/23 at 08:30 AM, with Administrative Nurse D, revealed the September 2023 log was not completed as staff compiled the logs at the end of the month, not on an ongoing basis to track and trend infections in real time. Administrative Nurse D stated staff discuss infections in Risk Meetings, but actual tracking and trending of infections was done at the end of the month. The facility policy Infection Surveillance Overview, undated, instructed staff that infection prevention begins with ongoing surveillance to identify infections that are causing or have potential to cause an outbreak in the facility. Surveillance is crucial in the identification of possible clusters, changes in prevalent organisms or increases in the rate of infections…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-10-04 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - Review of Resident (R)11's electronic medical record (EMR) revealed diagnoses which included: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and weakness. The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She required limited assistance of one staff for locomotion on the unit with the use of a wheelchair. The Activity of Daily Living (ADL)/Rehabilitation Potential CAA, dated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-04 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - Review of Resident (R)21's Physician Order Sheet, dated 08/09/23 revealed diagnoses included vascular dementia (progressive mental disorder characterized by failing memory, confusion) with agitation, delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The admission Minimum Data Set (MDS), dated [DATE], assessed the resident without use of antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication during the seven days look back period. Furthermore, the MDS indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-04 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - Review of Resident (R)11's electronic medical record (EMR) revealed diagnoses which included: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and weakness. The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She required extensive assistance of two staff for toileting and had two or more non-injury falls since the prior assessment. The Falls CAA, dated 07/03/23, documented the resident had several falls the past two months due to poor safety awareness. The Quarterly MDS, dated 04/05/23, documented the resident had a BIMS score of six, indicating severe cognitive…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - Review of Resident (R)14's Physician Order Sheet, dated 09/12/23, revealed diagnoses that included Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), cerebral vascular accident (CVA or stroke which is the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain, hemiplegia (paralysis of one side of the body), and hemiparesis (weakness on one side of the body). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - Review of Resident (R)11's electronic medical record (EMR) revealed diagnoses which included: Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and weakness. The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. She required extensive assistance of two staff for toileting and limited assistance of one staff for locomotion on the unit with the use of a wheelchair. She was always incontinent of bladder and frequently…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-10-04 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - Review of Resident (R)14's Physician Order Sheet, dated 09/12/23, revealed diagnoses that included Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), cerebral vascular accident (CVA or stroke which is the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain, hemiplegia (paralysis of one side of the body), and hemiparesis (weakness on one side of the body). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-10-04 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — an excerpt from the official record, may be distressing
The 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. Findings included: - Review of five Certified Nurse Aides (CNA), employed by the facility for greater than one year, revealed the following concern: CNA P, hired 08/01/22, lacked an annual performance review in her personnel file. On 10/03/23 at 03:23 PM, Administrative Nurse D stated not all the staff annual evaluations had been completed. The facility policy for Guidelines for Completion of Annual Evaluation Forms, effective 03/01/22, included: Supervisors will complete an annual evaluation for each employee annually to include a plan for professional or personal work-related goals. The facility failed to complete an annual performance review at least once every 12 months for this CNA, hired 08/01/22, to ensure adequate appropriate cares and services…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · C2025-03-31 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
The 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. Findings included: - A review of the facility's Daily Staffing Sheets from 02/01/25 through 03/25/25, revealed the actual hours worked were not completed on the daily staffing sheets. On 03/27/25 at 11:03 AM, Administrative Nurse D confirmed the actual hours worked were not completed on the daily staffing sheets. The facility policy for Daily Staff Posting, revised 10/07/24, included: The facility will post specific information regarding nurse staffing including the total number of staff and the actual hours worked per shift.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to CSJ INITIATIVES — 2 facilities. Here is how its ratings compare with the chain’s average across all its homes:
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.5 | +0.5 vs chain |
| Health inspection | 4 of 5 | 4.0 | ≈ chain avg |
| Staffing | 5 of 5 | 4.0 | +1.0 vs chain |
| Quality measures | 3 of 5 | 3.5 | -0.5 vs chain |
The other 1 home this chain runs (chain average 4.5★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| CONGREGATION OF THE SISTERS OF ST JOSEPH INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 12/01/2017 |
| BISE, DAVID | Individual | CONTRACTED MANAGING EMPLOYEE; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL | — | since 03/28/2018 |
| BERGEN, PATRICIA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 07/04/2014 |
| CONWAY, NANCY | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 07/04/2014 |
| KREYENBUHL, JOAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 07/09/2014 |
| O'BRIEN, MARGUERITE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 07/04/2014 |
| PARKS, CHRISTINE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 07/09/2014 |
| QUICK, MICHAEL | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| SCHAB, TAMI | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| TEICHMAN, RITA ANN | Individual | CORPORATE DIRECTOR | — | since 12/01/2017 |
| CSJ INITIATIVES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 12/01/2017 |
| SLATER, WILLIAM | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | since 03/28/2018 |
CMS files one row per role, so the 19 rows in the source record cover these 12 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $646K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in KS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175561. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-03-31, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.