Villa Maria
116 S Central Ave, Mulvane, KS 67110
Villa Maria, a 64-bed non profit - corporation nursing facility in Mulvane, KS, holds a 5-star CMS overall rating - well above the 3.0-star national average, with nurse staffing above the national norm. No recent finding reached the actual-harm level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 3167771129
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- 5 / 5
- Much above average · CMS overall · nat'l 3.0
- 3.92
- About average · nurse hrs/day · nat'l 3.89
- 18
- Inspection findings
- $22K
- Federal penalties (1)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 175456
- Ownership
- Non profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 64
- Residents
- 55
- In Hospital
- No
- County
- Sumner
- Last Inspection
- Dec 17, 2024
Staffing Data
How the 3.92 total nursing hours per resident-day are staffed:
- RN Hours
- 0.67 (nat'l avg: 0.68)
- LPN Hours
- 0.65
- CNA Hours
- 2.61
- Total Nursing Hours
- 3.92 (nat'l avg: 3.89)
- PT Hours
- 0.06
- Nursing Turnover
- 75.0%
- RN Turnover
- 83.3%
What the CMS Record Reveals About Villa Maria
Villa Maria operates 64 certified beds in Mulvane, KS with approximately 55 residents currently in care, and carries a CMS overall rating of 5 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (5★), staffing levels (3★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 18 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $22K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.92 total nursing hours per resident day (national average 3.89), with RN coverage at 0.67 per resident day, the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Villa Maria falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 75.0%, above the level where continuity of care typically begins to suffer. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (18 most recent)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 19, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Mar 22, 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.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 22, 2023
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 22, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 22, 2023
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 22, 2023
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Category: Resident Rights Deficiencies
Corrected: Mar 22, 2023
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Mar 22, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: May 26, 2021
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: May 26, 2021
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: May 26, 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.
Category: Pharmacy Service Deficiencies
Corrected: May 26, 2021
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Category: Pharmacy Service Deficiencies
Corrected: May 26, 2021
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: May 26, 2021
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: May 26, 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.
Category: Quality of Life and Care Deficiencies
Corrected: May 26, 2021
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: May 26, 2021
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 26, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 20.7% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 2.3% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 6.2% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 26.2% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 6.0% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 11.3% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.1% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 4.9% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 0.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 19.3% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 27.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 91.6% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 100.0% | No |
Penalty History 1 penalties totaling $22K
| Date | Type | Amount |
|---|---|---|
| Jan 16, 2025 | Fine | $22K |
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Understanding Nursing Home Data
Frequently Asked Questions
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What quality measures are tracked for Villa Maria?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
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