Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MOUNT ST MARY
WICHITA, KS · 24 certified beds · Last Life Safety survey March 31, 2025
CMS Certification Number 175561 · first certified March 2018
Ownership
Operated by CSJ INITIATIVES · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within KS
18 citations — more than 18% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 14 citations; the earlier surveys in the window averaged 2. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 2 months from now. This facility’s last Life Safety survey was March 2025. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
6 of the 18 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 18 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 18 |
| Median facility in KS | 27 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 20, 2022 | 0 |
| October 4, 2023 | 4 |
| March 31, 2025 | 14 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 2 | 2025-03-31 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2025-03-31 |
| E-0015 | Address subsistence needs for staff and patients. | 1 | 2025-03-31 |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | 1 | 2025-03-31 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 1 | 2025-03-31 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2025-03-31 |
| E-0023 | Establish policies and procedures for medical documentation. | 1 | 2025-03-31 |
| E-0034 | Provide a means of sharing information on occupancy/needs. | 1 | 2025-03-31 |
What the citations cover
- Smoke Deficiencies 9
- Emergency Preparedness Deficiencies 6
- Services Deficiencies 1
- Miscellaneous Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Emergency Preparedness Deficiencies | 6 |
| Services Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 31, 2025 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 6, 2025) |
October 4, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 1, 2023) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (December 1, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 1, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (December 1, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.