| Villa Maria | |
| 116 S Central Ave, Mulvane, Kansas 67110 | |
| (316) 777-1129 | |
| Name | Villa Maria |
|---|---|
| Location | 116 S Central Ave, Mulvane, Kansas |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 64 |
| Occupancy Rate | 88.91% |
| Medicare ID (CCN) | 175456 |
| Legal Business Name | Villa Maria Inc |
| Ownership Type | Non Profit - Corporation |
| NPI Number | 1366438657 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Villa Maria, Inc. |
| Address | 116 S Central Ave, Mulvane, KS 67110 |
| Phone Number | 316-777-1129 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 3.92 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.62 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 0.5 | 0.86 |
| Nurse aide hours per resident per day | 2.8 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 3.59 | 3.42 |
| RN hours per resident per day on the weekend | 0.39 | 0.48 |
| Physical therapist hours per resident per day | 0.1 | 0.07 |
| Total nursing staff turnover | 65.8% | 45.8% |
| Registered nurse turnover | 76.9% | 42.9% |
| Number of administrators who have left the nursing home | 1 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 1 |
| Total Amount of Fines in Dollars | $22,081 |
| Number of Payment Denials | 0 |
| Total Number of Penalties | 1 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Jul 30, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Aug 19, 2025 |
| Feb 8, 2023 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Mar 22, 2023 |
| Feb 8, 2023 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. F0582, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Mar 22, 2023 |
| Feb 8, 2023 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. F0657, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by Mar 22, 2023 |
| Feb 8, 2023 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Mar 22, 2023 |
| Feb 8, 2023 | Provide enough food/fluids to maintain a resident's health. F0692, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Mar 22, 2023 |
| Feb 8, 2023 | 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. F0700, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Mar 22, 2023 |
| Feb 8, 2023 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Mar 22, 2023 |
| Apr 20, 2021 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by May 26, 2021 |
| Apr 20, 2021 | Dispose of garbage and refuse properly. F0814, Nutrition and Dietary, Standard inspection | Potential for harm, widespread | Corrected by May 26, 2021 |
| Apr 20, 2021 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, widespread | Corrected by May 26, 2021 |
| Apr 20, 2021 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. F0661, Resident Assessment and Care Planning, Standard inspection | Potential for harm, isolated | Corrected by May 26, 2021 |
| Apr 20, 2021 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by May 26, 2021 |
| Apr 20, 2021 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by May 26, 2021 |
| Apr 20, 2021 | Provide safe and appropriate respiratory care for a resident when needed. F0695, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by May 26, 2021 |
| Apr 20, 2021 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. F0756, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by May 26, 2021 |
| Apr 20, 2021 | Ensure each resident’s drug regimen must be free from unnecessary drugs. F0757, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by May 26, 2021 |
| Apr 20, 2021 | 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. F0758, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by May 26, 2021 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.76 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 3.68 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 3.91 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 0 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.74 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.47 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.91 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.47 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 22.21 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 7.5 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.03 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 9.49 | 15.38 |