Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
VILLA ST FRANCIS CATHOLIC CARE CENTER INC
OLATHE, KS · 170 certified beds · Last Life Safety survey December 31, 2024
CMS Certification Number 175115 · first certified April 1978
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.
Position within KS
42 citations — more than 88% 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
The latest survey found 9 citations; the earlier surveys in the window averaged 16.5. 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 November 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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8 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.
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 42 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 42 |
| Median facility in KS | 27 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 27, 2021 | 19 |
| May 23, 2023 | 14 |
| December 31, 2024 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2024-12-31 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2024-12-31 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 3 | 2024-12-31 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 3 | 2024-12-31 |
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2024-12-31 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2023-05-23 |
| K-0161 | Use approved construction type or materials. | 2 | 2023-05-23 |
| 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 | 2023-05-23 |
What the citations cover
- Smoke Deficiencies 15
- Gas, Vacuum, and Electrical Systems Deficiencies 9
- Miscellaneous Deficiencies 7
- Egress Deficiencies 5
- Other 6
| Category | Citations |
|---|---|
| Smoke Deficiencies | 15 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 9 |
| Miscellaneous Deficiencies | 7 |
| Egress Deficiencies | 5 |
| Construction Deficiencies | 3 |
| Services Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 31, 2024 — 9 citations
| 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 (March 14, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (February 12, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted (February 12, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 14, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 14, 2025) |
May 23, 2023 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0111 | Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Deficient, Provider has date of correction (July 12, 2023) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (July 12, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 12, 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 (July 12, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 12, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 12, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (July 12, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 12, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 12, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 12, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 12, 2023) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (July 12, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 12, 2023) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (July 12, 2023) |
September 27, 2021 — 19 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (December 8, 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 (December 8, 2021) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (December 8, 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 (December 8, 2021) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (December 8, 2021) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 8, 2021) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (December 8, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (December 8, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 8, 2021) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 8, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 8, 2021) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 8, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted (December 8, 2021) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (December 8, 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 (December 8, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 8, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 8, 2021) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 8, 2021) |
| K-0930 | Ensure proper storage of liquid oxygen. | Deficient, Provider has date of correction (December 8, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.