Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

VILLA MARIA

MULVANE, KS · 64 certified beds · Last Life Safety survey December 17, 2024

CMS Certification Number 175456 · first certified August 2002

Ownership

Independently operated (no chain recorded by CMS) · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within KS

33 citations — more than 70% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 8 citations; the earlier surveys in the window averaged 12.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: August 2026 to October 2026. This facility’s last Life Safety survey was December 2024. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

2 of the 33 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 33 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	33
Median facility in KS	27
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
April 20, 2021	14
February 8, 2023	11
December 17, 2024	8

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2024-12-17
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	3	2024-12-17
K-0222	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.	2	2023-02-08
K-0324	Provide properly protected cooking facilities.	2	2024-12-17
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2024-12-17
K-0712	Have simulated fire drills held at unexpected times.	2	2024-12-17
K-0920	Ensure proper usage of power strips and extension cords.	2	2024-12-17
K-0923	Have proper medical gas storage and administration areas.	2	2023-02-08

What the citations cover

Citations by CMS category

Smoke Deficiencies 11
Gas, Vacuum, and Electrical Systems Deficiencies 8
Miscellaneous Deficiencies 5
Egress Deficiencies 5
Other 4

Citations by CMS category
Category	Citations
Smoke Deficiencies	11
Gas, Vacuum, and Electrical Systems Deficiencies	8
Miscellaneous Deficiencies	5
Egress Deficiencies	5
Emergency Preparedness Deficiencies	2
Services Deficiencies	1
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

December 17, 2024 — 8 citations

Citations issued on December 17, 2024
Tag	What the surveyor checks	Status
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (January 23, 2025)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (January 23, 2025)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (January 15, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 14, 2025)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (January 22, 2025)
K-0753	Have restrictions on the use of highly flammable decorations.	Deficient, Provider has date of correction (January 15, 2025)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (January 20, 2025)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (January 16, 2025)

February 8, 2023 — 11 citations

Citations issued on February 8, 2023
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (March 10, 2023)
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (March 10, 2023)
K-0222	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.	Deficient, Provider has date of correction (March 10, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (March 10, 2023)
K-0325	Have properly installed hallway dispensers for alcohol-based hand rub.	Deficient, Provider has date of correction (March 10, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (March 10, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (March 10, 2023)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (March 10, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (March 10, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (March 10, 2023)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (March 10, 2023)

April 20, 2021 — 14 citations

Citations issued on April 20, 2021
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (July 29, 2021)
K-0222	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.	Deficient, Provider has date of correction (July 29, 2021)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (July 29, 2021)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (July 29, 2021)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (July 29, 2021)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (July 29, 2021)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (July 29, 2021)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (July 29, 2021)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (July 29, 2021)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (July 29, 2021)
K-0711	Provide a written emergency evacuation plan.	Deficient, Provider has date of correction (July 29, 2021)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (July 29, 2021)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (July 29, 2021)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (July 29, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.