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.

42
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
13
Tags cited more than once
Across separate surveys
22
Inspection & testing records
Of the citations on file

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

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

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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Which alerts

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

  • 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.

This facility42KS median27National median11
Citations on file over three years, compared
MeasureCitations
This facility42
Median facility in KS27
Median facility nationally11

Survey history

Citations at each Life Safety survey
192021-09142023-0592024-12
Citations at each Life Safety survey
Survey dateCitations
September 27, 202119
May 23, 202314
December 31, 20249

Most-cited tags

Most-cited tags at this facility
K-09183K-03453K-03723K-05113K-03633K-07122K-01612K-02222
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0918Have generator or other power source capable of supplying service within 10 seconds.32024-12-31
K-0345Have approved installation, maintenance and testing program for fire alarm systems.32024-12-31
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.32024-12-31
K-0511Have properly installed electrical wiring and gas equipment.32024-12-31
K-0363Install corridor and hallway doors that block smoke.32024-12-31
K-0712Have simulated fire drills held at unexpected times.22023-05-23
K-0161Use approved construction type or materials.22023-05-23
K-0222Add 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.22023-05-23

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 15
  • Gas, Vacuum, and Electrical Systems Deficiencies 9
  • Miscellaneous Deficiencies 7
  • Egress Deficiencies 5
  • Other 6
Citations by CMS category
CategoryCitations
Smoke Deficiencies15
Gas, Vacuum, and Electrical Systems Deficiencies9
Miscellaneous Deficiencies7
Egress Deficiencies5
Construction Deficiencies3
Services Deficiencies3

Every citation on file

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

December 31, 2024 — 9 citations

Citations issued on December 31, 2024
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (March 14, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Waiver has been granted (February 12, 2025)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (March 14, 2025)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (March 14, 2025)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (March 14, 2025)
K-0753Have restrictions on the use of highly flammable decorations.Deficient, Provider has date of correction (March 14, 2025)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Waiver has been granted (February 12, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (March 14, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (March 14, 2025)

May 23, 2023 — 14 citations

Citations issued on May 23, 2023
TagWhat the surveyor checksStatus
K-0111Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.Deficient, Provider has date of correction (July 12, 2023)
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (July 12, 2023)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (July 12, 2023)
K-0222Add 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-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (July 12, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (July 12, 2023)
K-0362Ensure 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-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (July 12, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (July 12, 2023)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (July 12, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (July 12, 2023)
K-0753Have restrictions on the use of highly flammable decorations.Deficient, Provider has date of correction (July 12, 2023)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (July 12, 2023)
K-0926Ensure 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

Citations issued on September 27, 2021
TagWhat the surveyor checksStatus
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (December 8, 2021)
K-0222Add 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-0281Install proper backup exit lighting.Deficient, Provider has date of correction (December 8, 2021)
K-0321Ensure 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-0343Have 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-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (December 8, 2021)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (December 8, 2021)
K-0353Inspect, test, and maintain automatic sprinkler systems.Waiver has been granted (December 8, 2021)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (December 8, 2021)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (December 8, 2021)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (December 8, 2021)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (December 8, 2021)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Waiver has been granted (December 8, 2021)
K-0781Have restrictions on the use of portable space heaters.Deficient, Provider has date of correction (December 8, 2021)
K-0914Ensure 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-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (December 8, 2021)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (December 8, 2021)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (December 8, 2021)
K-0930Ensure 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.