5/5
CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
5/5
CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
With 44 beds, Villa Maria is a skilled nursing and short-term rehabilitation community on East Main Street in Mulvane, Kansas. Asc Health System operates the facility. The community cares for residents recovering from surgery, hospitalization, and acute illness who require nursing support and rehabilitation services. Medicare, Medicaid, and private pay are accepted, giving families several options when arranging care.
Rehabilitation is a major focus at Villa Maria. Residents have access to both outpatient therapy and dedicated rehabilitation services designed to help them regain function and independence. Daily nurse staffing averages 4 hours and 41 minutes per resident. Registered nurses provide about 30 minutes of care each day, while nurse aides contribute 2 hours and 34 minutes of direct care.
The facility’s staffing levels support its rehabilitation-focused approach. Residents stay an average of 227 days as they work toward recovery goals and more independence. With nursing care and therapy services combined, residents can be supported throughout the rehabilitation process.
State inspections have reviewed areas such as documentation practices, resident assessments, medication management, facility maintenance, and infection control. Earlier surveys identified concerns in these areas. The facility addressed the cited deficiencies and showed improvement through successful follow-up reviews. No fines or enforcement actions were recorded.
The community is in a somewhat walkable part of Mulvane. A few nearby services may be reached by walking, but most errands and appointments require transportation. The quieter setting may appeal to residents and families looking for a less urban environment while still having access to local services and community resources.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
|
30m per day | ▼ 29% State avg: 43m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
|
26m per day | ▼ 35% State avg: 40m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
|
2h 34m per day | ▼ 5% State avg: 2h 41m per day · National avg: 2h 20m per day |
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
|
3h 5m per day | ▼ 14% State avg: 3h 35m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
|
5m per day | ▲ 163% State avg: 2m per day · National avg: 4m per day |
|
Weekend RN
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
|
17m per day | ▼ 43% State avg: 30m per day · National avg: 28m per day |
Lower than the Kansas average: 79.5%
Villa Maria, Inc is administered by Teresa Ballard.
In Kansas, the Department for Aging and Disability Services, Survey and Certification Commission performs the unannounced inspections required for facility licensing and federal certification.
This scorecard compares key inspection, deficiency, and complaint metrics at this facility against the Kansas state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies
|
This Facility | KS Average | vs. KS Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
|
35 | 100 | This facility has 65% fewer total deficiencies than a typical Kansas assisted living residence (35 vs. KS avg 100).↓ 65% better |
|
Deficiencies per year
Average deficiencies per year since 2014.
|
2.9 | 8.3 | This facility has 65% fewer deficiencies per year than a typical Kansas assisted living residence (2.9 vs. KS avg 8.3).↓ 65% better |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
State average N/A
Last Health inspection on Jul 2025
State average N/A
State average N/A
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
10 of 18 citations resulted from standard inspections; 1 of 18 resulted from complaint investigations; and 7 of 18 came from combined inspections (standard and complaint).
In line with State average
State average: N/A
In line with State average
State average: N/A
Corrected
Corrected
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
0% compared with State average
State average ratio: 0 : 0
0% compared with State average
State average: 0 hours
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
All 20 RN Staff are full-time employees. No contractors work on this role.
20
Average shift length. Calculated as total hours divided by days worked and average staff per day.
10.7 hours
Assists with medical care and medications.
All 16 LPN Staff are full-time employees. No contractors work on this role.
16
Average shift length. Calculated as total hours divided by days worked and average staff per day.
10.3 hours
Helps with daily care and mobility.
All 192 CNA Staff are full-time employees. No contractors work on this role.
192
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.6 hours
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
92 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 192 | 0 | 192 | 11,496 | 92 | 100% | 7.6 |
| Licensed Practical Nurse | 16 | 0 | 16 | 2,248 | 91 | 99% | 10.3 |
| Medication Aide/Technician | 51 | 0 | 51 | 2,195 | 92 | 100% | 8.5 |
| Registered Nurse | 20 | 0 | 20 | 2,042 | 92 | 100% | 10.7 |
| Dietitian | 2 | 0 | 2 | 969 | 70 | 76% | 8.3 |
| Nurse Practitioner | 2 | 0 | 2 | 568 | 63 | 68% | 8 |
| Dental Services Staff | 1 | 0 | 1 | 503 | 61 | 66% | 8.2 |
| Respiratory Therapy Technician | 1 | 0 | 1 | 468 | 66 | 72% | 7.1 |
| Administrator | 1 | 0 | 1 | 456 | 57 | 62% | 8 |
| Physical Therapy Assistant | 1 | 0 | 1 | 353 | 58 | 63% | 6.1 |
| Qualified Social Worker | 1 | 0 | 1 | 309 | 52 | 57% | 5.9 |
| Other Dietary Services Staff | 2 | 0 | 2 | 303 | 64 | 70% | 4.6 |
| Speech Language Pathologist | 2 | 0 | 2 | 114 | 31 | 34% | 3.5 |
| Clinical Nurse Specialist | 2 | 0 | 2 | 96 | 12 | 13% | 8 |
| RN Director of Nursing | 1 | 0 | 1 | 64 | 8 | 9% | 8 |
| Medical Director | 0 | 1 | 1 | 60 | 15 | 16% | 4 |
| Occupational Therapy Assistant | 0 | 1 | 1 | 32 | 8 | 9% | 4 |
| Physical Therapy Aide | 1 | 0 | 1 | 14 | 4 | 4% | 3.4 |
Includes penalties issued in 2025
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database (Data as of Jan 2026)
23% lower than State average
State average: $44K
59% fewer fines than State average
State average: 2.4
Serious action where Medicare and/or Medicaid temporarily stops payments for new residents until issues are fixed.
0
100% fewer payment denials than State average
State average: 0.3
Penalties are imposed by CMS for violations of federal nursing home regulations.
1 penalty in the past 3 years
Jan 16, 2025 · $34K
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
Jan 16, 2025
Last updated: Jan 2026
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
11.9
13% worse than State average
State average: 10.5
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
23.0
11% worse than State average
State average: 20.7
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
17.2%
10% better than State average
State average: 19.0%
Percent of long-stay residents whose ability to move independently worsened
23.4%
21% worse than State average
State average: 19.4%
Percent of low risk long-stay residents who lose control of their bowels or bladder
28.4%
19% worse than State average
State average: 23.8%
Percent of long-stay residents experiencing one or more falls with major injury
8.3%
90% worse than State average
State average: 4.4%
Percent of long-stay high risk residents with pressure ulcers
4.9%
5% worse than State average
State average: 4.6%
Percent of long-stay residents with a urinary tract infection
2.3%
27% better than State average
State average: 3.1%
Percent of long-stay residents who lose too much weight
5.6%
9% worse than State average
State average: 5.1%
Percent of long-stay residents who have depressive symptoms
0.0%
100% better than State average
State average: 5.2%
Percent of long-stay residents who received an antipsychotic medication
10.6%
37% better than State average
State average: 16.9%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
100.0%
9% better than State average
State average: 91.9%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
100.0%
5% better than State average
State average: 95.5%
Number of hospitalizations per 1,000 long-stay resident days.
1.91
In line with State average
State average: 1.84
Number of outpatient emergency department visits per 1,000 long-stay resident days.
1.52
30% better than State average
State average: 2.16
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
98.4%
30% better than State average
State average: 75.6%
Percent of short-stay residents who newly received an antipsychotic medication
0.0%
100% better than State average
State average: 2.2%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
100.0%
36% better than State average
State average: 73.5%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
22.3%
In line with State average
State average: 23.0%
Percentage of short-stay residents who had an outpatient emergency department visit.
2.8%
76% better than State average
State average: 11.7%
Percentage of SNF residents who experience falls with major injury during their stay.
2.0%
155% worse than State average
State average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
53.7%
In line with State average
State average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
64.6%
28% better than State average
State average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
38% of new residents, usually for short-term rehab.
44% of new residents, often for short stays.
17% of new residents, often for long-term daily care.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
46
Residents meet regularly to discuss policies, care quality, and activities
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Historical financial and operational data for Villa Maria, Inc from 2012–2024, based on CMS SNF Cost Reports.
Based on CMS SNF Cost Report for fiscal year ending in 06/2024.
Net patient revenue — what the home actually collects for resident care, after contractual allowances, bad debt and discounts are subtracted from its gross charges (CMS cost report, Worksheet G-3). It covers resident care only; money the home earns from other sources is shown separately as "Other income."
Net patient income: net patient revenue minus the home's total operating expenses. A positive figure means it earns more from resident care than it spends to deliver it; a negative figure means the opposite. It excludes non-operating "other income."
Net patient revenue — what the home actually collects for resident care, after contractual allowances, bad debt and discounts are subtracted from its gross charges (CMS cost report, Worksheet G-3). It covers resident care only; money the home earns from other sources is shown separately as "Other income."
Net patient income: net patient revenue minus the home's total operating expenses. A positive figure means it earns more from resident care than it spends to deliver it; a negative figure means the opposite. It excludes non-operating "other income."
Money the home earns outside of resident care — such as investments, grants, rentals and other non-operating sources (CMS cost report, Worksheet G-3). It is tracked separately from net patient revenue: it is not part of that figure, and it is not included in net patient income.
Staff salaries plus wage-related costs — benefits such as payroll taxes, health insurance and retirement — from the home's own accounting records (CMS cost report, Worksheet A). Contract or agency labor is counted separately, under other operating costs.
Payroll as a share of revenue: staff salaries and wage-related benefits divided by net patient revenue. A higher figure means more of each revenue dollar goes to staff pay.
Everything it costs to run the home apart from payroll — food, utilities, supplies, maintenance, contract labor and administration. Calculated as total operating expense minus payroll (staff salaries and wage-related benefits).
The home's total operating expense for the year — all the costs of running it, salaries included (CMS cost report, Worksheet G-3).
This home supports both short-term rehab and long-term care, with residents staying for a wide range of durations.
New residents most often arrive under private pay (44% of admissions), and a typical private pay stay runs around 4 - 5 months.
Coverage residents most often arrive under.
Coverage residents most often leave under.
0.0 miles from city center
Estimated distance in miles from Mulvane's city center to Villa Maria, Inc's address, calculated via Google Maps.
Add your location
The information below is reported by the Kansas Department for Aging and Disability Services.
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| Villa Maria, Inc |
NH
AL
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Mulvane | - | 44 | - | 49 | - |
| Homestead of Osawatomie |
NH
AL
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Osawatomie | - | 40 | - | 13 | Suite |
| Brookdale Rosehill |
NH
AL
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Shawnee | - | 92 | A+ | 54 | Studio / 1 Bed |
| Ascension Living Via Christi Village McLean |
NH
AL
IL
MC
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Wichita (Indian Hills) | - | 95 | - | 47 | Studio / 1 Bed |
| Ascension Living Via Christi Village Manhattan |
NH
AL
IL
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Manhattan (Willow Grove Road) | - | 129 | - | 10 | Studio / 1 Bed / 2 Bed |
Villa Maria, Inc has a walk score of 49. Somewhat walkable. A few nearby services may be reachable on foot, but most trips require transportation.
Villa Maria, Inc's occupancy is 70%.
Villa Maria, Inc is registered as a non-profit in KS.
Teresa Ballard is the administrator of Villa Maria, Inc.
Villa Maria, Inc has 44 beds.
Yes — there are 2 photos of Villa Maria, Inc in the photo gallery on this page.
Villa Maria, Inc is located at 633 E Main Street, Mulvane, KS 67110.
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