MOUNT ST MARY

WICHITA, KS · 24 beds · Non profit - Corporation

99 Trust Score

Grade: A+ LOW Risk → Stable

Red Flags

No red flags identified.

Green Flags

✓ 4-star health inspection rating
✓ 5-star staffing rating
✓ No fines or penalties on record
✓ Above-average RN staffing (1.23 hrs vs 0.80 state avg)

Quick Facts

★★★★★

CMS Overall

★★★★☆

Health Inspection

0.6x state avg

Deficiencies

Fines (3-yr)

★★★★★

Staffing

Violation Timeline

March 30, 2025

6 deficiencyies

F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0695 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide safe and appropriate respiratory care for a resident when needed.

F0697 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide safe, appropriate pain management for a resident who requires such services.

F0730 Potential Harm Scope/Severity: F

Nursing and Physician Services Deficiencies

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Observe each nurse aide's job performance and give regular training.

F0732 No Harm Scope/Severity: C

Nursing and Physician Services Deficiencies

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Post nurse staffing information every day.

F0758 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

October 3, 2023

8 deficiencyies

F0641 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Ensure each resident receives an accurate assessment.

F0656 Potential Harm Scope/Severity: E

Resident Assessment and Care Planning Deficiencies

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Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0657 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

F0677 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide care and assistance to perform activities of daily living for any resident who is unable.

F0689 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0690 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

F0730 Potential Harm Scope/Severity: D

Nursing and Physician Services Deficiencies

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Observe each nurse aide's job performance and give regular training.

F0880 Potential Harm Scope/Severity: F

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

See full violation history →

Staffing

1.23

RN hrs/res/day

1.04

LPN hrs/res/day

4.59

CNA hrs/res/day

6.24

Weekend hrs/res/day

35%

Total nurse turnover

40%

RN turnover

A nurse checks on each resident roughly every 3.5 hours on average.

Fines & Penalties

No fines or penalties on record.

Ownership

Non profit - Corporation Independent (not part of a chain)

CONGREGATION OF THE SISTERS OF ST JOSEPH INC

5% OR GREATER DIRECT OWNERSHIP INTEREST

Since since 12/01/2017

100% Organization
CSJ INITIATIVES INC

OPERATIONAL/MANAGERIAL CONTROL

Since since 12/01/2017

Organization
BISE, DAVID

OPERATIONAL/MANAGERIAL CONTROL

Since since 12/01/2017

Individual
SLATER, WILLIAM

OPERATIONAL/MANAGERIAL CONTROL

Since since 03/28/2018

Individual
BERGEN, PATRICIA

CORPORATE DIRECTOR

Since since 07/04/2014

Individual
CONWAY, NANCY

CORPORATE DIRECTOR

Since since 07/04/2014

Individual
KREYENBUHL, JOAN

CORPORATE DIRECTOR

Since since 07/09/2014

Individual
O'BRIEN, MARGUERITE

CORPORATE DIRECTOR

Since since 07/04/2014

Individual
PARKS, CHRISTINE

CORPORATE DIRECTOR

Since since 07/09/2014

Individual
QUICK, MICHAEL

CORPORATE DIRECTOR

Since since 07/01/2017

Individual
SCHAB, TAMI

CORPORATE DIRECTOR

Since since 07/01/2017

Individual
TEICHMAN, RITA ANN

CORPORATE DIRECTOR

Since since 12/01/2017

Individual
BERGEN, PATRICIA

CORPORATE OFFICER

Since since 07/04/2014

Individual
BISE, DAVID

CORPORATE OFFICER

Since since 03/28/2018

Individual
CONWAY, NANCY

CORPORATE OFFICER

Since since 07/04/2014

Individual
KREYENBUHL, JOAN

CORPORATE OFFICER

Since since 07/09/2014

Individual
O'BRIEN, MARGUERITE

CORPORATE OFFICER

Since since 12/15/2017

Individual
PARKS, CHRISTINE

CORPORATE OFFICER

Since since 07/09/2014

Individual
BISE, DAVID

CONTRACTED MANAGING EMPLOYEE

Since since 12/01/2017

Individual