Mount St Mary
3700 E Lincoln St, Wichita, KS 67218
Mount St Mary is a nursing home in Wichita, Kansas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 5 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (316) 686-7171
- Last standard health inspection
- March 31, 2025 (1 year ago)
- Certified beds
- 24
- Residents per day, on average
- 20.8
- Ownership type
- Non profit - Corporation
- Legal business name
- Mount St Mary INC
- Chain
- Csj Initiatives
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Kansas average (14 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of May 27, 2026
Ownership
CMS lists this home under a new chain.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
6 citations
Health inspection on March 31, 2025
CMS lists this as a standard inspection and a complaint inspection.
Citation F0730. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on April 23, 2025.
CMS has cited this home for F0730 2 times since 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 23, 2025.
CMS has cited this home for F0656 2 times since 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on April 23, 2025.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on April 23, 2025.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 23, 2025.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on April 23, 2025.
14 citations
Fire safety inspection on March 31, 2025
CMS lists this as a standard inspection.
Citation E0009. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Include a process for Emergency Preparedness collaboration.
CMS lists it as corrected on June 6, 2025.
Citation E0015. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on June 6, 2025.
Citation E0023. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for medical documentation.
CMS lists it as corrected on June 6, 2025.
Citation E0033. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish methods for sharing information.
CMS lists it as corrected on June 6, 2025.
Citation E0034. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a means of sharing information on occupancy/needs.
CMS lists it as corrected on June 6, 2025.
Citation E0035. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide family notifications of emergency plan.
CMS lists it as corrected on June 6, 2025.
Citation K0211. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on June 6, 2025.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on June 6, 2025.
Citation K0346. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
CMS lists it as corrected on June 6, 2025.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on June 6, 2025.
Citation K0362. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on June 6, 2025.
CMS has cited this home for K0362 2 times since 2023.
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on June 6, 2025.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on June 6, 2025.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on June 6, 2025.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Staffing
Total nurse staffing reported to CMS went from 5.1 to 4.5 hours per resident per day.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 4 of 5.
CMS update of January 31, 2024
Star rating
The CMS health inspection star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
8 citations
Health inspection on October 4, 2023
CMS lists this as a standard inspection.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 3, 2023.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on November 3, 2023.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on November 3, 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on November 3, 2023.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on November 3, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 3, 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on November 3, 2023.
Citation F0730. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on November 3, 2023.
4 citations
Fire safety inspection on October 4, 2023
CMS lists this as a standard inspection.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on December 1, 2023.
Citation K0343. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
CMS lists it as corrected on December 1, 2023.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 1, 2023.
Citation K0362. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on December 1, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CONGREGATION OF THE SISTERS OF ST JOSEPH INC5% or greater direct ownership interest · 100% · since 12/01/2017
- CSJ INITIATIVES INCOperational/managerial control · not applicable · since 12/01/2017
- BISE, DAVIDOperational/managerial control · not applicable · since 12/01/2017
- SLATER, WILLIAMOperational/managerial control · not applicable · since 03/28/2018
Questions
When was Mount St Mary last inspected?
CMS lists March 31, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Mount St Mary have?
CMS lists 14 health citations since October 4, 2023. CMS also calls these deficiencies.
Has Mount St Mary been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Mount St Mary?
Its CMS overall star rating is 5 of 5.
Is Mount St Mary a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.