Inspection Reports for Villa Maria, Inc
633 E MAIN STREET, MULVANE, KS, 67110
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 27, 2025, found that all previously cited deficiencies had been corrected. Prior inspections showed some deficiencies related mainly to resident care issues such as failure to perform required functional capacity screenings, medication administration errors, and incomplete documentation of assistive devices. Earlier reports also noted facility maintenance and infection control concerns, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Complaint investigations included one substantiated case involving resident elopement linked to care and safety lapses, while most other complaints were unsubstantiated. The facility appears to have addressed prior deficiencies effectively, showing improvement by resolving cited issues in the most recent revisit.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
31 residents
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Re-Inspection
Deficiencies: 5
Date: Oct 27, 2025
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by regulation numbers 26-41-101 (f)(1), 26-41-204 (i), 26-41-205 (b), 26-41-205 (d)(1-2), and 26-41-205 (i) were corrected as of the revisit date 10/27/2025.
Deficiencies (5)
Deficiency related to regulation 26-41-101 (f)(1)
Deficiency related to regulation 26-41-204 (i)
Deficiency related to regulation 26-41-205 (b)
Deficiency related to regulation 26-41-205 (d)(1-2)
Deficiency related to regulation 26-41-205 (i)
Report Facts
Deficiencies corrected: 5
Inspection Report
Re-Inspection
Census: 31
Deficiencies: 5
Date: Oct 2, 2025
Visit Reason
The inspection was a licensure resurvey with an attached complaint number 191889 conducted on 10/01/25 and 10/02/25.
Complaint Details
The inspection included complaint number 191889 related to resident elopement and neglect.
Findings
The facility was found deficient in multiple areas including failure to perform a Functional Capacity Screening after a resident's change in cognition leading to elopement, failure to document and assess a bed assist device properly, failure to identify responsibility for medication administration in the negotiated service agreement, failure to administer medications according to provider orders, and failure to properly document destruction of controlled medications.
Deficiencies (5)
Facility nurse neglected to perform a Functional Capacity Screening reflecting a resident's change in cognition; staff failed to acknowledge door alarm system leading to resident elopement.
Operator failed to assess and document bed assist device for risk of entrapment and usage instructions in resident's service agreement and health plan.
Negotiated Service Agreement did not identify who was responsible for administration and management of selected medications for a resident self-administering insulin.
Licensed nurse administered medications not in accordance with medical provider's written order; missing order for saline enema and lack of documentation of provider notification.
Failure to ensure destruction of controlled medications was performed by two licensed nurses or a licensed nurse and pharmacist as required.
Report Facts
Census: 31
Deficiencies cited: 5
Medication wasted: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA C | Certified Medication Aide | Named in controlled medication destruction finding |
| Licensed Nurse B | Licensed Nurse | Named in controlled medication destruction and medication administration findings |
| Operator A | Operator | Interviewed regarding multiple deficiencies including elopement and medication administration |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 1, 2025
Visit Reason
The document is a plan of correction addressing findings from a licensure resurvey with an attached complaint number 191889 conducted on October 1 and 2, 2025.
Complaint Details
The inspection included an attached complaint number 191889.
Findings
The plan of correction corresponds to citations found during the licensure resurvey and complaint investigation conducted on the specified dates.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 30, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-07-06.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 2023-07-30, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 35
Deficiencies: 4
Date: Jul 6, 2023
Visit Reason
The inspection was a licensure resurvey with an attached complaint number 173230 conducted on 07/05/23 and 07/06/23 at Maria Court.
Complaint Details
The inspection included an attached complaint number 173230.
Findings
The facility was found deficient in multiple areas including failure to ensure licensed nurses performed proper assessments of bed devices to confirm they were not restraints, failure to label over-the-counter medications with resident names, non-compliance with tuberculosis screening guidelines for new hires and residents, and multiple facility maintenance issues compromising health and safety.
Deficiencies (4)
Failure to ensure licensed nurse performed assessments ensuring bed devices were not restraints, including proper documentation and secure attachment for residents R1, R2, and R3.
Failure to ensure licensed pharmacist or nurse placed full resident names on over-the-counter medication bottles.
Failure to comply with tuberculosis screening guidelines for adult care homes for resident R3 and newly hired dietary staff E.
Failure to maintain facility to protect health and safety of residents, personnel, and the public, including issues such as low battery on carbon monoxide detector, peeling wallpaper, unpainted walls, open screw holes, non-working equipment blocking heating units, lint and dust buildup on vents, cracked molding, burned out lights, stained carpet, musty odor, and door latch taped preventing proper closure.
Report Facts
Census: 35
OTC medication bottles unlabeled: 7
Dates of resident admissions: R1 admitted 07/06/18, R2 admitted 03/09/19, R3 admitted 05/09/23.
Bed device dimensions: Half rails measured 31 inches wide by 18 inches high; bed assist device 14 inches wide by 41 inches high.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
The document is a plan of correction submitted in response to findings from a licensure resurvey with an attached complaint number 173230 conducted on 07/05/23 and 07/06/23.
Complaint Details
The inspection was conducted with an attached complaint number 173230.
Findings
The plan of correction addresses citations resulting from the licensure resurvey and complaint investigation conducted on the specified dates.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 6, 2023
Visit Reason
The licensure resurvey with attached complaint number 186177 was conducted on 03/05/23 and 03/06/23 at the assisted living facility.
Complaint Details
Complaint number 186177 was attached to the licensure resurvey; no deficiencies were found.
Findings
The inspection resulted in a finding of no deficiency citations.
Report Facts
Complaint number: 186177
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 5, 2023
Visit Reason
The licensure resurvey with attached complaint number 186177 was conducted on 03/05/23 and 03/06/23 at the assisted living facility.
Findings
The inspection resulted in a finding of no deficiency citations.
Inspection Report
Renewal
Deficiencies: 0
Date: Dec 27, 2021
Visit Reason
The licensure resurvey was conducted on 12/27/2021 and 12/28/2021 at the assisted living facility to assess compliance for license renewal.
Findings
The resurvey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 27, 2021
Visit Reason
The licensure resurvey was conducted on 12/27/2021 and 12/28/2021 at the assisted living facility to assess compliance.
Findings
The resurvey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Routine
Deficiencies: 0
Date: Jul 27, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 07/27/2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 1, 2018
Visit Reason
The visit was a resurvey conducted to verify correction of previous deficiencies at the facility.
Findings
The resurvey on 2018-05-01 resulted in a finding of no deficiency citations.
Inspection Report
Abbreviated Survey
Census: 35
Deficiencies: 3
Date: Aug 1, 2016
Visit Reason
The visit was an abbreviated survey conducted on 7-26-16, 7-27-16, 7-28-16, and 8-1-16 to assess compliance with health care service requirements and delegation of duties in an assisted living facility.
Findings
The facility failed to ensure licensed nurses provided or coordinated necessary health care services in accordance with Functional Capacity Screening and Negotiated Service Agreements for residents #1 and #3. Deficiencies included lack of interventions for infection risk related to chemotherapy and MRSA wound care, failure to delegate nursing procedures appropriately to certified medication aides, and inadequate documentation and care plans addressing wound care, chemotherapy pump management, and infection control.
Deficiencies (3)
Failure to ensure licensed nurse provided or coordinated necessary health care services per Functional Capacity Screening and Negotiated Service Agreement for residents #1 and #3.
Failure to include interventions in Health Care Service Plan for infection risk related to chemotherapy and MRSA wound care.
Failure to appropriately delegate nursing procedures to certified medication aides related to wound care and care of resident with chemotherapy port.
Report Facts
Census: 35
Wound size: 14
Wound size: 7
Wound size: 0.2
Absolute Neutrophils range: 0.40 to 1.64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse A | Interviewed and confirmed lack of interventions and delegation related to chemotherapy port care | |
| licensed staff B | Confirmed wound care deficiencies and non-compliance with wound vac; signed notes on wound care | |
| certified staff C | Signed notes on wound vac tube kink and infection control procedures | |
| certified staff D | Signed notes on wound vac tubing reconnected | |
| licensed staff E | Signed notes on wound vac non-compliance and resident education | |
| certified staff F | Interviewed regarding infection control procedures | |
| operator/licensed staff | Signed notes on wound care education and resident compliance discussion |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 11, 2016
Visit Reason
The resurvey at the facility was conducted on 2016-07-06 and 2016-07-11 to verify compliance and check for deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations at the facility.
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 26, 2014
Visit Reason
The licensure resurvey was conducted as a renewal inspection of the facility.
Findings
The licensure resurvey resulted in a finding of no deficiency citations on 8-25-14 and 8-26-14.
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