Derby Health & Rehabilitation, LLC
Derby · 5.2 mi · 74 beds
Citations0Substantiated0
Villa Maria
116 S CENTRAL AVE, Mulvane, KS, 67110
Nursing home64 licensed beds0 citations on record
2 more within 6 milesOpen in Maps
Has this facility been cited?
Yes. Federal inspectors cited 1 deficiency against Villa Maria in Mulvane, Kansas at its most recent standard inspection on 2024-12-17, 1 of them arising from complaints. Medicare has fined it 1 time, totalling $22,081. Medicare rates it 5 out of 5 overall.
5 / 5Medicare overall rating
64certified beds
1deficiencies at the last inspection
0immediate-jeopardy findings on record
0actual-harm findings on record
1federal fines, $22,081
What the inspectors found
Every deficiency on record, by how serious CMS judged it
CMS grades each finding from A to L on two axes: how badly residents were affected, and how many. These are its bands, not ours. The figures cover every standard and complaint survey on record, which is a longer window than the rating cycle above.
Immediate jeopardyA resident was placed in immediate danger. The most serious band CMS uses.0
Actual harmA resident was harmed, but not placed in immediate danger.0
Potential for more than minimal harmNo resident was harmed, but the failing could have caused it.18
Potential for minimal harmThe least serious band.0
Most recentDDDDDDDDFFFDDDDDDD
The last 18 findings, newest first
Each is the federal requirement the home was found not to meet, in CMS’s own wording, with the tag number so it can be looked up against the inspection report.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2025-07-30 · from a complaint · No actual harm, potential for more than minimal harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies · F0550 · 2023-02-08 · standard survey · No actual harm, potential for more than minimal harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Resident Rights Deficiencies · F0582 · 2023-02-08 · standard survey · No actual harm, potential for more than minimal harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies · F0657 · 2023-02-08 · standard survey · No actual harm, potential for more than minimal harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · F0686 · 2023-02-08 · standard survey · No actual harm, potential for more than minimal harm
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · F0692 · 2023-02-08 · standard survey · No actual harm, potential for more than minimal harm
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Quality of Life and Care Deficiencies · F0700 · 2023-02-08 · standard survey · No actual harm, potential for more than minimal harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies · F0755 · 2023-02-08 · standard survey · No actual harm, potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · F0812 · 2021-04-20 · standard survey · No actual harm, potential for more than minimal harm
Dispose of garbage and refuse properly.
Nutrition and Dietary Deficiencies · F0814 · 2021-04-20 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2021-04-20 · standard survey · No actual harm, potential for more than minimal harm
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Resident Assessment and Care Planning Deficiencies · F0661 · 2021-04-20 · standard survey · No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2021-04-20 · standard survey · No actual harm, potential for more than minimal harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies · F0690 · 2021-04-20 · standard survey · No actual harm, potential for more than minimal harm
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · F0695 · 2021-04-20 · standard survey · No actual harm, potential for more than minimal harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · F0756 · 2021-04-20 · standard survey · No actual harm, potential for more than minimal harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · F0757 · 2021-04-20 · standard survey · No actual harm, potential for more than minimal harm
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies · F0758 · 2021-04-20 · standard survey · No actual harm, potential for more than minimal harm
Medicare’s own rating
How CMS scores this home
These stars are Medicare’s, not ours — we publish no rating of our own. They are reproduced here because they are part of the public record.
OverallCombines the three below5 of 5
Health inspectionBased on the last three inspection cycles5 of 5
StaffingNurse hours per resident, adjusted for how sick residents are3 of 5
Quality measuresResident outcomes reported by the home4 of 5
Nurse hours per resident per dayReported by the home to CMS3.91738
Nursing staff turnoverShare of nursing staff who left in a year65.8%
Penalties
What Medicare has fined this home
FinesCivil money penalties imposed by CMS1
Total fined$22,081
Payment denials and other penaltiesMedicare refusing to pay for new admissions is the usual one1
Ownership
Who owns Villa Maria
Nursing homes are frequently owned through layers of companies, and the name over the door is rarely the one that holds the licence. This is the ownership CMS has on file.
| Owner | Role | Share | Since |
|---|---|---|---|
| BURRUS, MICHAEL | Individual | NOT APPLICABLE | since 05/15/2025 |
| CAMPBELL, BRIAN | Individual | NOT APPLICABLE | since 05/15/2025 |
| ETHEREDGE, WESLEY | Individual | NOT APPLICABLE | since 05/15/2025 |
| HAMPEL, MELICIA | Individual | NOT APPLICABLE | since 05/15/2025 |
| HOFFMAN, MARK | Individual | NOT APPLICABLE | since 05/15/2025 |
| LAFLEUR, CYNTHIA | Individual | NOT APPLICABLE | since 05/15/2025 |
| LAZAR, JERALD | Individual | NOT APPLICABLE | since 05/15/2025 |
| MACIAS, JEAN | Individual | NOT APPLICABLE | since 05/15/2025 |
| MEIER, CONNOR | Individual | NOT APPLICABLE | since 05/15/2025 |
| POOL, SUSAN | Individual | NOT APPLICABLE | since 05/15/2025 |
| SCHUMER, MARY | Individual | NOT APPLICABLE | since 05/15/2025 |
| STRECKER, KEVIN | Individual | NOT APPLICABLE | since 05/15/2025 |
Nearby
Other licensed providers within six miles
Listed by distance. Nobody paid to appear here and the order is not for sale.
Westview of Derby Rehabilitation & Health Care Cen
Derby · 5.2 mi · 78 beds
Citations0Substantiated0
Contact
Ask Villa Maria a question
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Source: Centers for Medicare & Medicaid Services, Nursing Home Care Compare. Retrieved 2026-07-29. Facility number 175456.
Figures reproduce the state’s own totals and are not re-aggregated. Methodology · Report a correction