Inspection Reports for
Villa Maria, Inc
633 E MAIN STREET, MULVANE, KS, 67110
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
4.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
70% occupied
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Follow-Up
Deficiencies: 5
Date: Oct 27, 2025
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies have been corrected and to confirm the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies listed with regulation numbers were corrected as of the revisit date. The report confirms completion of corrective actions for multiple regulatory items.
Deficiencies (5)
26-41-101 (f) (1): Previously cited deficiency corrected as of 10/27/2025.
26-41-204 (i): Previously cited deficiency corrected as of 10/27/2025.
26-41-205 (b): Previously cited deficiency corrected as of 10/27/2025.
26-41-205 (d) (1-2): Previously cited deficiency corrected as of 10/27/2025.
26-41-205 (i): Previously cited deficiency corrected as of 10/27/2025.
Inspection Report
Renewal
Census: 31
Deficiencies: 5
Date: Oct 2, 2025
Visit Reason
Licensure resurvey with attached complaint number 191889 conducted on 10/01/25 and 10/02/25.
Complaint Details
Complaint number 191889 was attached to this licensure resurvey.
Findings
The facility was found deficient in multiple areas including failure to prevent resident elopement, inadequate documentation and assessment of assistive devices, incomplete medication administration agreements, failure to follow medical orders, and improper destruction of controlled medications.
Deficiencies (5)
26-41-101 (f) (1) Staff Treatment of Residents: The facility nurse neglected to perform a Functional Capacity Screening after a change in cognition and failed to monitor door alarms, resulting in resident R4 eloping and being at immediate jeopardy for approximately 50 minutes.
26-41-204 (i) Health Care Services Standards of Practice: The operator failed to assess and document the description, purpose, and monitoring instructions of a bed assist device for resident R3 in the negotiated service agreement and health service plan.
26-41-205 (b) Administration of Selected Medications: The negotiated service agreement for resident R3 did not identify who was responsible for administration of insulin when R3 self-administered.
26-41-205 (d) Facility Administration of Medications: Licensed nurse failed to administer resident R2's medications according to medical provider's written orders, including undocumented verbal order for saline enema.
26-41-205 (i) Disposition of Medication: The facility failed to ensure destruction of controlled medications was performed by two licensed nurses or a licensed nurse and a licensed pharmacist, as evidenced by controlled medication wastage signed only by a certified medication aide and a licensed nurse.
Report Facts
Resident census: 31
Deficiencies cited: 5
Controlled medication tablets wasted: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse B | Licensed Nurse | Named in findings related to medication administration and controlled medication destruction. |
| CMA C | Certified Medication Aide | Named in findings related to controlled medication destruction. |
| Operator A | Facility operator interviewed regarding deficiencies and corrective actions. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 1, 2025
Visit Reason
The plan of correction addresses findings from the licensure resurvey with attached complaint number 191889 conducted on October 1 and 2, 2025.
Findings
The document references citations from the licensure resurvey and complaint investigation but does not provide specific findings or deficiency details.
Inspection Report
Annual Inspection
Census: 57
Deficiencies: 1
Date: Jul 30, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulations and ensure resident safety.
Findings
The facility failed to ensure an environment free from accident hazards when staff did not assess Resident 1's ability to safely manage hot liquids, resulting in a hot liquid spill and a burn injury. The facility lacked a policy for hot beverage safety and had not assessed residents for safety with hot liquids.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in a resident sustaining a burn from hot coffee. The facility did not have a policy for hot beverage safety and did not assess residents for safety with hot liquids.
Report Facts
Resident census: 57
Burn area measurement: 13.61
Burn area measurement: 5.85
Burn area measurement: 59.59
Hot liquid temperature limit: 120
Hot liquid temperature observed: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Assessed resident after hot liquid spill and noted burn injury |
| Certified Nurse Aide M | Certified Nurse Aide | Reported giving resident breakfast tray and observed coffee spill and burn |
| Certified Nurse Aide N | Certified Nurse Aide | Observed coffee temperature and reported hot beverage lid policy |
| Licensed Nurse H | Licensed Nurse | Commented on hot liquid policy after spill incident |
| Administrative Nurse D | Administrative Nurse | Discussed hot beverage safety with staff and reported expectations |
| Administrative Staff A | Administrative Staff | Reported on staff education and policy development for hot beverages |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at the nursing home facility.
Findings
No health deficiencies were found during the inspection.
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 07/06/23.
Findings
All deficiencies cited in the prior inspection have been corrected as of 07/30/23, 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 complaint number 173230 and found deficiencies related to device assessments, medication labeling, tuberculosis screening, and facility maintenance.
Findings
The facility failed to ensure licensed nurses performed proper assessments of bed devices to confirm they were not restraints and documented periodic reassessments for residents R1, R2, and R3. The facility also failed to label over-the-counter medications with residents' full names, comply with tuberculosis screening guidelines for new employees and residents, and maintain the facility to protect health and safety, including addressing maintenance issues such as peeling wallpaper, burned out lights, and a beeping carbon monoxide detector.
Deficiencies (4)
K.A.R. 26-41-204 (i) The facility failed to ensure licensed nurses assessed bed devices to confirm they were not restraints, determined residents' ability to safely use the devices, ensured devices were securely attached, included device descriptions in service agreements, and documented periodic reassessments for residents R1, R2, and R3.
K.A.R. 26-41-205 (g) (3) The facility failed to ensure licensed pharmacists or nurses placed the full name of the resident on over-the-counter medication bottles.
K.A.R. 26-41-207 (b) (5-6) (c) The facility failed to comply with tuberculosis screening guidelines by not performing required 2-step TB tests within 7 days of employment for a newly hired employee and not repeating TB skin tests for resident R3 at admission.
K.A.R. 28-39-254 (a) The facility was not maintained to protect health and safety, with issues including a low battery carbon monoxide detector beeping, 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, and a door with tape preventing proper latching.
Report Facts
Resident census: 35
Unlabeled OTC medications: 7
Dates of TB tests: Historical TB tests for resident R3 dated 10/18/22 and 10/25/22
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 5, 2023
Visit Reason
The document is a plan of correction responding to findings from a licensure resurvey with an attached complaint number 173230 conducted on July 5 and 6, 2023.
Findings
The plan of correction addresses citations identified during the licensure resurvey and complaint investigation conducted on July 5 and 6, 2023.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 6, 2023
Visit Reason
The licensure resurvey with attached complaint number 186177 was conducted to verify compliance and address the complaint.
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 at the assisted living facility.
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
Routine
Census: 57
Deficiencies: 8
Date: Feb 8, 2023
Visit Reason
Routine inspection of Villa Maria nursing home to assess compliance with regulatory requirements including resident dignity, care planning, pressure ulcer prevention, medication management, and safety.
Findings
The facility had multiple deficiencies including failure to maintain resident dignity by not covering urinary catheter bags, failure to provide required Medicare ABN forms to residents, incomplete care planning for bed rail use, inadequate pressure ulcer prevention and treatment, failure to implement dietician recommendations, failure to assess and obtain consent for bed rail use, and improper disposal of fentanyl patches.
Deficiencies (8)
F 0550: The facility failed to cover Resident 5's urinary catheter bag, placing the resident at risk for embarrassment and an undignified living environment.
F 0582: The facility failed to provide three residents or their representatives the completed Skilled Nursing Facility Advanced Beneficiary Notices (ABN) form 10055, placing them at risk to make uninformed decisions about their skilled care.
F 0657: The facility failed to care plan the use of bed rails for Resident 30, placing the resident at risk for impaired safety due to lack of staff direction for bed rail use.
F 0686: The facility failed to prevent development of facility-acquired pressure ulcers for Residents 33 and 34 and failed to implement treatment and interventions upon identification, placing residents at risk for further skin breakdown, pain, and infection.
F 0686: The facility failed to provide off-loading, repositioning, or follow dietician recommendations for Resident 33's wound care and treatment, placing the resident at risk for worsening wound and delayed healing.
F 0692: The facility failed to implement dietician's recommendations for Resident 33, placing the resident at risk for further weight loss, malnutrition, and delayed wound healing.
F 0700: The facility failed to assess Resident 30 for risk of entrapment from bed rails, obtain informed consent, and ensure bed rail dimensions were within recommended safe limits, placing the resident at risk for entrapment and injury.
F 0755: The facility failed to ensure staff disposed of Resident 10's fentanyl patch per standards and facility protocol, creating risk for diversion, illicit use, and accidental overdose.
Report Facts
Residents in census: 57
Sampled residents: 16
Bed rail gap width: 4.75
Fentanyl patch dosage: 25
Weight loss percentage: 7
Pressure ulcer wound size: 5.4
Inspection Report
Renewal
Deficiencies: 0
Date: Dec 28, 2021
Visit Reason
The licensure resurvey was conducted to renew the assisted living facility's license and verify compliance with regulatory requirements.
Findings
The licensure resurvey conducted on 12/27/2021 and 12/28/2021 resulted in no deficiency citations for 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.
Inspection Report
Routine
Census: 44
Deficiencies: 10
Date: Apr 20, 2021
Visit Reason
Routine state inspection of Villa Maria nursing home to assess compliance with healthcare regulations including resident care, medication management, infection control, and facility safety.
Findings
The facility had multiple deficiencies including failure to complete discharge summaries, inadequate fall prevention interventions, improper catheter care, unsanitary respiratory equipment maintenance, delayed pharmacist recommendation responses, improper medication management, unsanitary food preparation practices, improper garbage disposal, and inadequate COVID-19 infection control practices.
Deficiencies (10)
F0661: The facility failed to complete a discharge summary including recapitulation of stay, medication reconciliation, and disposition for resident R44.
F0689: The facility failed to ensure equipment was in proper working condition and failed to implement immediate interventions following multiple falls for resident R16.
F0690: The facility failed to keep urinary catheter tubing from touching the floor for resident R38, increasing risk of urinary tract infection.
F0695: The facility failed to maintain and properly clean respiratory equipment including oxygen concentrator and nebulizer for residents R13 and R34, increasing risk of respiratory infection.
F0756: The facility failed to timely act on consultant pharmacist recommendations for residents R11, R16, and R27, including medication adjustments and monitoring.
F0757: The facility failed to ensure residents R11 and R27 had blood glucose levels monitored and physician notified when levels were out of ordered parameters.
F0758: The facility failed to ensure residents R16 and R27 were free from unnecessary psychotropic medications and failed to implement gradual dose reductions or non-pharmacological interventions.
F0812: The facility failed to prepare and serve food under sanitary conditions by allowing use of unsanitizable personal frying pans brought from home.
F0814: The facility failed to properly dispose of kitchen garbage and refuse, including lack of a foot-operated trash can adjacent to the handwashing sink and use of an open barrel overflowing with paper towels next to bread rack.
F0880: The facility failed to follow CDC and CMS COVID-19 infection control recommendations including inadequate staff screening, failure to quarantine residents after staff positive test, allowing cloth/surgical masks during outbreak, and lacking outbreak response policy.
Report Facts
Residents present: 44
Residents reviewed: 12
Residents reviewed for medication: 5
Blood sugar readings above 300: 35
Blood sugar readings above 300: 34
Blood sugar readings above 300: 8
Falls: 10
Pharmacist recommendations delay: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Worked shifts while symptomatic with COVID-19, tested positive, and was not quarantined immediately |
| Administrative Nurse D | Administrative Nurse | Confirmed multiple deficiencies including failure to notify physician of blood sugar levels, delayed pharmacist recommendation follow-up, and COVID-19 outbreak management |
| Licensed Nurse I | Licensed Nurse | Reported on medication monitoring and pharmacist recommendation processes |
| Dietary Staff BB | Dietary Staff | Reported use of unsanitizable personal frying pans and improper trash disposal in kitchen |
Inspection Report
Routine
Deficiencies: 0
Date: Jul 27, 2020
Visit Reason
The visit was a special infection control survey for COVID-19 conducted at the facility.
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: 2
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 according to residents' functional capacity screenings and negotiated service agreements. Deficiencies included lack of interventions for infection risk, wound care, chemotherapy pump care, and failure to delegate nursing tasks appropriately to certified medication aides.
Deficiencies (2)
KAR 26-41-204(a) Health Care Services: The facility failed to ensure licensed nurses provided or coordinated necessary health care services for residents #1 and #3 according to their functional capacity screening and negotiated service agreement, including infection control and wound care.
KAR 26-41-204(e) Delegation of Duties: The licensed nurse failed to appropriately delegate nursing procedures related to wound care and care of a resident with a chemotherapy port to certified medication aides for residents #1 and #3.
Report Facts
Resident census: 35
Absolute Neutrophils range: 0.40 to 1.64
Wound size: 14 cm by 9 cm by 0.1 cm
Wound size: 14 cm by 7 cm by 0.2 cm
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 11, 2016
Visit Reason
The visit was a resurvey conducted on 2016-07-06 and 2016-07-11 to verify compliance following a previous inspection.
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 to assess compliance for renewal of the facility's license.
Findings
The licensure resurvey resulted in no deficiency citations on the dates of 2014-08-25 and 2014-08-26.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N096011 POC 9NIE11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility identified as ASPEN with State ID N096011.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N096011 POC UPHP11
Visit Reason
This document is a Plan of Correction related to a previous inspection or regulatory finding for the facility identified by State ID N096011 and Event ID UPHP11.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N096011 POC E04P11
Visit Reason
This document is a Plan of Correction related to a previous deficiency report for a facility identified as N096011.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the Plan of Correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N096011 POC UPHP12
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as State ID N096011.
Findings
No deficiency details or findings are included in this Plan of Correction document. It only references the associated deficiency report and provides contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N096011 POC GI3Z11
Visit Reason
This document is a plan of correction related to a prior deficiency report for the facility identified as N096011.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N096011 POC HIYE11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility identified by State ID N096011.
Findings
No deficiency details or findings are included in this document. It serves solely as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N096011 POC K3L511
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for the facility identified as Aspen.
Findings
No deficiency details or findings are included in this document. It serves solely as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N096011 POC KGT911
Visit Reason
This document is a plan of correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the plan of correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N096011 POC KGT912
Visit Reason
This document is a Plan of Correction related to a prior inspection or deficiency report for the facility identified by State ID N096011 and Event ID KGT912.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
Viewing
Loading inspection reports...
