Mount St Mary
Wichita, Sedgwick County, Kansas · CCN 175561 · Non-profit (Corporation) · part of Csj Initiatives (2 facilities, chain average 4.5 stars)
CMS rates Mount St Mary 5 of 5 overall as of August 2026. 24 certified beds, 21 residents a day on average. 14 citations on record from the current inspection cycles; no fines on record.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★★★ 5 of 5 |
|---|---|
| Health inspections | ★★★★☆ 4 of 5 |
| Staffing | ★★★★★ 5 of 5 |
| Quality measures | ★★★☆☆ 3 of 5 |
| Quality: long-stay / short-stay | 3 / — of 5 |
Staffing
| Total nurse staffing | 5.07868 hours per resident per day |
|---|---|
| Registered nurses | 0.95121 hours per resident per day |
| Weekend total | 4.65917 hours per resident per day |
| Nursing staff turnover | 31% (registered nurses 33.3%) |
| Administrators who left | 0 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2025-03-31 complaint survey |
Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · tag F0730 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2025-04-23 |
| 2025-03-31 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-23 |
| 2025-03-31 complaint survey |
Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-23 |
| 2025-03-31 complaint survey |
Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-23 |
| 2025-03-31 complaint survey |
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. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-23 |
| 2025-03-31 complaint survey |
Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2025-04-23 |
| 2023-10-04 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-11-03 |
| 2023-10-04 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-03 |
| 2023-10-04 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-03 |
| 2023-10-04 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-03 |
| 2023-10-04 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-03 |
| 2023-10-04 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-03 |
| 2023-10-04 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-03 |
| 2023-10-04 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · tag F0730 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-03 |
Fines and payment denials
No fines or payment denials on record since 2023.
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Congregation Of The Sisters Of St Joseph Inc. Organization | 5% or greater direct ownership interest | 100% | 2017-12-01 |
| Csj Initiatives Inc. Organization | operational/managerial control | — | 2017-12-01 |
| Bise, David Individual | contracted managing employee | — | 2017-12-01 |
| Bergen, Patricia Individual | corporate director | — | 2014-07-04 |
| Conway, Nancy Individual | corporate director | — | 2014-07-04 |
| Kreyenbuhl, Joan Individual | corporate director | — | 2014-07-09 |
| O'Brien, Marguerite Individual | corporate director | — | 2014-07-04 |
| Parks, Christine Individual | corporate director | — | 2014-07-09 |
| Quick, Michael Individual | corporate director | — | 2017-07-01 |
| Schab, Tami Individual | corporate director | — | 2017-07-01 |
| Teichman, Rita Ann Individual | corporate director | — | 2017-12-01 |
| Bergen, Patricia Individual | corporate officer | — | 2014-07-04 |
| Bise, David Individual | corporate officer | — | 2018-03-28 |
| Conway, Nancy Individual | corporate officer | — | 2014-07-04 |
| Kreyenbuhl, Joan Individual | corporate officer | — | 2014-07-09 |
| O'Brien, Marguerite Individual | corporate officer | — | 2017-12-15 |
| Parks, Christine Individual | corporate officer | — | 2014-07-09 |
| Bise, David Individual | operational/managerial control | — | 2017-12-01 |
| Slater, William Individual | operational/managerial control | — | 2018-03-28 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Mount St Mary.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Sedgwick County.