Public Record
Mount St Mary
From CMS
Facility profile
- CMS overall rating
- 5 / 5
- Certified beds
- 24
- Avg. residents per day
- 20.1
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 32
- Inspections on file
- 4
- Last inspection
- 2025-03-31
*CMS
*CMS
*CMS
Citations
32 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0697Generalpotential for harm
Provide safe, appropriate pain management for a resident who requires such services.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0758Generalpotential for harm
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.
- 0023Generalpotential for harm
Establish policies and procedures for medical documentation.
- 0033Generalpotential for harm
Establish methods for sharing information.
- 0034Generalpotential for harm
Provide a means of sharing information on occupancy/needs.
- 0035Generalpotential for harm
Provide family notifications of emergency plan.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0346Generalpotential for harm
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- 0354Generalpotential for harm
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- 0362Generalpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0009Generalpotential for harm
Include a process for Emergency Preparedness collaboration.
- 0015Generalpotential for harm
Address subsistence needs for staff and patients.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0362Generalpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0343Generalpotential for harm
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
FAQ
Questions and answers
- What is Mount St Mary?
- Mount St Mary is a Medicare- and Medicaid-certified nursing home in Wichita, KS, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 175561.
- What is the CMS rating for Mount St Mary?
- Mount St Mary has a CMS overall rating of 5 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Mount St Mary have?
- Mount St Mary is certified for 24 beds. It serves an average of 20.1 residents per day.
- How many citations does Mount St Mary have?
- Mount St Mary has 32 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Mount St Mary last inspected?
- Mount St Mary was last inspected on March 31, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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