Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mount St Mary during CMS and state inspections, most recent first.
The facility did not complete required annual performance reviews for a CNA and two CMAs who had been employed for over a year, as confirmed by administrative staff and a review of personnel files. Facility policy requires annual written evaluations for all employees.
A resident with COPD who used a non-invasive ventilator did not have staff instructions for the device included in the baseline care plan, and there was no physician's order for its use in the medical record. An administrative nurse confirmed the omission, despite facility policy requiring such instructions for effective care.
A resident with COPD was using a non-invasive ventilator without a physician's order, as required by facility policy. The care plan lacked staff instructions for the device, and staff confirmed the absence of the necessary order in the EMR.
A resident with chronic pain and severe cognitive impairment was managed solely with scheduled and PRN opioid pain medication, without any non-pharmacological interventions documented or offered, despite facility policy requiring such measures. Staff interviews confirmed a lack of awareness and implementation of non-pharmacological pain management strategies.
The facility did not complete or display accurate daily nurse staffing information, specifically omitting the actual hours worked by staff on required postings, as confirmed by an administrative nurse and a review of staffing records.
Failure to Complete Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for three staff members, including a Certified Nurse Aide and two Certified Medication Aides, all of whom had been employed for over one year. A review of five employee personnel files revealed that these three staff members did not have documented annual performance evaluations as required by facility policy. This was confirmed by the Administrative Nurse, who acknowledged the absence of the required evaluations. The facility's policy, revised earlier in the year, mandates a formal written evaluation of employee work performance annually.
Failure to Include Non-Invasive Ventilator in Baseline Care Plan
Penalty
Summary
The facility failed to develop a thorough baseline care plan for a resident with chronic obstructive pulmonary disease (COPD) who utilized a non-invasive mechanical ventilator. The resident's electronic medical record indicated a diagnosis of COPD and documented the use of a non-invasive ventilator, with fluctuating levels of staff assistance required due to respiratory function. Despite this, the care plan, last revised on 03/09/25, did not include any staff instructions regarding the use or management of the non-invasive ventilator. Additionally, the resident's electronic medical record did not contain a physician's order for the use of the non-invasive ventilator. An administrative nurse confirmed that the resident had required the device since admission and managed it herself, and acknowledged that the ventilator should have been included in the care plan but was not. The facility's policy required that baseline care plans include necessary instructions for effective care, which was not followed in this instance.
Failure to Obtain Physician's Order for Non-Invasive Ventilator
Penalty
Summary
A resident with a diagnosis of chronic obstructive pulmonary disease (COPD) was observed to be using a non-invasive mechanical ventilator since admission. The resident's electronic medical record (EMR) and care plan did not contain a physician's order for the use of the non-invasive ventilator, nor did the care plan provide staff instructions regarding its use. The facility's policy requires an order from the resident's physician for the use and settings of the non-invasive ventilator, as well as documentation of its use and the resident's response. Interviews with the resident, a licensed nurse, and an administrative nurse confirmed that the facility lacked the required physician's order for the non-invasive ventilator. The absence of this order was acknowledged by staff, who stated it was the facility's expectation to have such an order in place. The facility's policy also mandates following the manufacturer's instructions for cleaning the device, but the primary deficiency identified was the lack of a physician's order for the ventilator.
Failure to Provide Non-Pharmacological Pain Interventions
Penalty
Summary
A resident with a diagnosis of chronic pain and severe cognitive impairment was not provided with non-pharmacological interventions for pain management, as required by facility policy. The resident's electronic medical record and care plan documented the use of scheduled and PRN pain medications, specifically Tramadol, but did not include any non-pharmacological pain management strategies. The resident received PRN Tramadol multiple times over a period, with pain ratings ranging from three to nine on a ten-point scale. Interviews with facility staff, including a CNA, CMA, and an administrative nurse, confirmed that the only pain intervention available to the resident was medication, and that staff were unaware of or did not implement non-pharmacological interventions. The facility's pain management policy required the inclusion of such interventions, but this was not reflected in the resident's care plan or practice.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to display accurate and publicly accessible nurse staffing information on a daily basis for all 22 residents. A review of the facility's Daily Staffing Sheets over nearly two months revealed that the actual hours worked by staff were not completed on these sheets. This omission was confirmed by an administrative nurse during an interview. The facility's own policy required posting of specific nurse staffing details, including the total number of staff and the actual hours worked per shift, but this was not followed as documented in the findings.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 323 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wichita
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincoln Care And Rehab | 0.3 mi | ★★★★★ | 0 | 0 |
| Orchard Gardens | 1.8 mi | ★★★★★ | 7 | 0 |
| Medicalodges Wichita | 1.8 mi | ★★★★★ | 21 | 0 |
| Life Care Center Of Wichita | 2 mi | ★★★★★ | 0 | 0 |
| Legacy At College Hill | 3.6 mi | ★★★★★ | 17 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.