A+
96/100MOUNT ST MARY Inspection Report, Violations & Safety Grade (WICHITA, Kansas)
3700 E LINCOLN ST, WICHITA, Kansas 67218
Phone: 3166867171
CMS Overall:5/5
Overview & Bed Count
Certified Beds
24
Avg Residents/Day
20.8
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Sedgwick
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall5/5
Health4/5
Staffing5/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Kansas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.97 | 0.73 | +0.24 |
| Total Nurse Hours per Resident per Day | 4.76 | 4.13 | +0.62 |
| CMS Staffing Rating | 5/5 | 3.5/5 | - |
| Nursing Staff Turnover | 44.4% | 48% | - |
Health Citation History
14 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-03-31 | Nursing and Physician Services Deficiencies | Observe each nurse aide's job performance and give regular training. | F – Moderate Harm Potential |
| 2025-03-31 | 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. | D – Moderate Harm Potential |
| 2025-03-31 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2025-03-31 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | D – Moderate Harm Potential |
| 2025-03-31 | 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. | D – Moderate Harm Potential |
| 2025-03-31 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | C – Minimal Harm Potential |
| 2023-10-04 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2023-10-04 | 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. | E – Moderate Harm Potential |
| 2023-10-04 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2023-10-04 | 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. | D – Moderate Harm Potential |
| 2023-10-04 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2023-10-04 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2023-10-04 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2023-10-04 | Nursing and Physician Services Deficiencies | Observe each nurse aide's job performance and give regular training. | D – Moderate Harm Potential |
Fire Safety Citation History
18 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-03-31 | Emergency Preparedness Deficiencies | Include a process for Emergency Preparedness collaboration. | F – Moderate Harm Potential |
| 2025-03-31 | Emergency Preparedness Deficiencies | Address subsistence needs for staff and patients. | F – Moderate Harm Potential |
| 2025-03-31 | Emergency Preparedness Deficiencies | Establish policies and procedures for medical documentation. | F – Moderate Harm Potential |
| 2025-03-31 | Emergency Preparedness Deficiencies | Establish methods for sharing information. | F – Moderate Harm Potential |
| 2025-03-31 | Emergency Preparedness Deficiencies | Provide a means of sharing information on occupancy/needs. | F – Moderate Harm Potential |
| 2025-03-31 | Emergency Preparedness Deficiencies | Provide family notifications of emergency plan. | F – Moderate Harm Potential |
| 2025-03-31 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | F – Moderate Harm Potential |
| 2025-03-31 | Smoke Deficiencies | Provide properly protected cooking facilities. | F – Moderate Harm Potential |
| 2025-03-31 | Smoke Deficiencies | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | F – Moderate Harm Potential |
| 2025-03-31 | Smoke Deficiencies | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | F – Moderate Harm Potential |
| 2025-03-31 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | F – Moderate Harm Potential |
| 2025-03-31 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | F – Moderate Harm Potential |
| 2025-03-31 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2025-03-31 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2023-10-04 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | F – Moderate Harm Potential |
| 2023-10-04 | Smoke Deficiencies | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | D – Moderate Harm Potential |
| 2023-10-04 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2023-10-04 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | D – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
Need Help Finding Safe Care?
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the WICHITA area at no cost.
Find Safe, Vetted Facilities Near WICHITA
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.