Cycle 1
Health 2024-12-17 · Fire 2024-12-17
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Mulvane, KS
Villa Maria
5-star overall rating with 5-star inspections with $22,081 in total fines with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
116 S Central Ave, Mulvane, KS
(316) 777-1129
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.67
Registered nurse staffing
LPN hours / resident day
0.65
Licensed practical nurse staffing
Aide hours / resident day
2.61
Nurse aide staffing
Weekend hours
3.33
Weekend nurse staffing
RN turnover
83%
Annual RN turnover
Total nurse turnover
75%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
4.4%
1.8 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.6%
5.6 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.9% |
5.0%
0.1 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.3% |
23.2%
3.9 pts better
|
19.6%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.3% |
19.8%
8.5 pts better
|
16.7%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.2% |
18.4%
7.8 pts worse
|
16.3%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
18.8%
1.9 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
3.1%
0.8 pts better
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
23.2%
3.8 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
4.6%
1.4 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
75.6%
16 pts better
|
81.7%
9.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.8% |
11.7%
8.9 pts better
|
12.0%
9.2 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.2%
1.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
73.5%
26.5 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
23.0%
0.7 pts better
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-08 · Fire 2023-02-08
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2021-04-20 · Fire 2021-04-20
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-01-23
F · Potential for more than minimal harm
2024-12-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-14
F · Potential for more than minimal harm
2024-12-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-22
F · Potential for more than minimal harm
2024-12-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-20
E · Potential for more than minimal harm
2024-12-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-23
E · Potential for more than minimal harm
2024-12-17
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-01-15
E · Potential for more than minimal harm
2024-12-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-16
F · Potential for more than minimal harm
2023-02-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-02-08
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-02-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-02-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-02-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-03-10
F · Potential for more than minimal harm
2023-02-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-02-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-02-08
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-03-10
E · Potential for more than minimal harm
2023-02-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-02-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-10
F · Potential for more than minimal harm
2021-04-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-04-20
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-04-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-04-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-04-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-04-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-04-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-04-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-04-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-04-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-04-20
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-04-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2021-07-29
F · Potential for more than minimal harm
2021-04-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-04-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-07-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-19
D · Potential for more than minimal harm
2023-02-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-02-08
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-02-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-02-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-02-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-02-08
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-02-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-22
F · Potential for more than minimal harm
2021-04-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-05-26
F · Potential for more than minimal harm
2021-04-20
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2021-05-26
F · Potential for more than minimal harm
2021-04-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-04-20
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-04-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-04-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-04-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-04-20
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-04-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-05-26
D · Potential for more than minimal harm
2021-04-20
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-05-26
Penalties and ownership
What sits behind the stars
$22,081
2025-01-16
Fine
Fine · fine $22,081
Fine
Ownership
Asc Health System
5% Or Greater Direct Ownership Interest · Organization
Asc Health System
5% Or Greater Security Interest · Organization
Cillessen, Kathy
Corporate Director · Individual
Houser, Cynthia
Corporate Director · Individual
Hufford, David
Corporate Director · Individual
Johnson, Jackie
W-2 Managing Employee · Individual
Magana, Christopher
Corporate Director · Individual
Morgan, Charles
Corporate Officer · Individual
Oblinger, Warren
Corporate Officer · Individual
Renz, Jan
Corporate Director · Individual
Schumer, Mary
Corporate Director · Individual
Smith, Sidney
Operational/Managerial Control · Individual
Smith, Sidney
Corporate Officer · Individual
Sorensen, Melinda
Corporate Officer · Individual
Steadman, Kyle
Corporate Officer · Individual
Via Christi Villages Inc
Operational/Managerial Control · Organization
Wetta, Therese
Corporate Director · Individual
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