Villa Maria
116 S Central Ave, Mulvane, KS 67110
Villa Maria is a nursing home in Mulvane, 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
- 5 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (316) 777-1129
- Last standard health inspection
- September 9, 2026 (2 months ago)
- Certified beds
- 64
- Residents per day, on average
- 53.8
- Ownership type
- Non profit - Corporation
- Legal business name
- Villa Maria INC
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Kansas average (13 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.
5 citations
Health inspection on September 9, 2026
CMS lists this as a standard inspection.
Citation F0636. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Citation F0640. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Citation F0638. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assure that each resident’s assessment is updated at least once every 3 months.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of June 24, 2026
Ownership
CMS ownership records list new owners for this home.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.9 to 3.5 hours per resident per day.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Fine
CMS changed the fine from January 16, 2025 from $33,970 to $22,081.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
1 citation
Health inspection on July 30, 2025
CMS lists this as a complaint inspection.
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 August 19, 2025.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of March 26, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 5 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 5 of 5.
Fine
January 16, 2025 (1 year ago)
CMS fine of $22,081 on January 16, 2025.
CMS update of December 20, 2024
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 3 of 5.
8 citations
Fire safety inspection on December 17, 2024
CMS lists this as a standard inspection.
Citation K0161. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on January 23, 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 January 15, 2025.
CMS has cited this home for K0324 2 times since 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 14, 2025.
CMS has cited this home for K0353 3 times since 2021.
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 January 22, 2025.
CMS has cited this home for K0712 2 times since 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 20, 2025.
CMS has cited this home for K0918 3 times since 2021.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
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 January 23, 2025.
CMS has cited this home for K0321 2 times since 2021.
Citation K0753. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on January 15, 2025.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on January 16, 2025.
CMS has cited this home for K0920 2 times since 2023.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of August 29, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 1 of 5.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
7 citations
Health inspection on February 8, 2023
CMS lists this as a standard inspection.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on March 22, 2023.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on March 22, 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 March 22, 2023.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on March 22, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on March 22, 2023.
Citation F0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 22, 2023.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on March 22, 2023.
11 citations
Fire safety inspection on February 8, 2023
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on March 10, 2023.
Citation E0007. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address patient/client population and determine types of services needed.
CMS lists it as corrected on March 10, 2023.
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 March 10, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 10, 2023.
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 March 10, 2023.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on March 10, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on March 10, 2023.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 10, 2023.
CMS has cited this home for K0222 2 times since 2021.
Citation K0325. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed hallway dispensers for alcohol-based hand rub.
CMS lists it as corrected on March 10, 2023.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on March 10, 2023.
CMS has cited this home for K0923 2 times since 2021.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on March 10, 2023.
14 citations
Fire safety inspection on April 20, 2021
CMS lists this as a standard inspection.
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 July 29, 2021.
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on July 29, 2021.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on July 29, 2021.
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on July 29, 2021.
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 July 29, 2021.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on July 29, 2021.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on July 29, 2021.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on July 29, 2021.
Citation K0374. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on July 29, 2021.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on July 29, 2021.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on July 29, 2021.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on July 29, 2021.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on July 29, 2021.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on July 29, 2021.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CATHOLIC CARE CENTER INCOperational/managerial control · not applicable · since 07/01/2025
- IPC HEALTHCARE INCOperational/managerial control · not applicable · since 05/01/2020
- BRETTON, ANGELICAOperational/managerial control · not applicable · since 05/15/2025
- MCCUE, TAMARAOperational/managerial control · not applicable · since 05/01/2020
Questions
When was Villa Maria last inspected?
CMS lists September 9, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Villa Maria have?
CMS lists 13 health citations since February 8, 2023. CMS also calls these deficiencies.
Has Villa Maria been fined?
CMS lists 1 fine in the past three years, $22,081 in total.
What is the CMS star rating of Villa Maria?
Its CMS overall star rating is 5 of 5.
Is Villa Maria a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.