Federal inspection record · CMS data as of October 1, 2026
Cheyenne County Village Inc
820 S Denison Street, St Francis, KS · (785) 332-2531
- Certified beds
- 30
- Residents per day
- 28
- Ownership
- Non-Profit
- Chain
- Grace Team Services
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- June 1, 1995
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
-
Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Kansas.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Kansas homes
Cheyenne County Village Inc carries 65.75 inspection points. That is fewer than 50% of Kansas's 293 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Kansas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–27 pts
- 4★ 27–49 pts
- 3★ 49–71 pts
- 2★ 71–114.38 pts
- 1★ over 114.38 pts
Bars show every rated home in Kansas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
31 health citations on record since 2022. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
-
G
Provide safe, appropriate pain management for a resident who requires such services.
Everything else, by area of care
Quality of Life and Care8D
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Resident Assessment and Care Planning6D
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Infection Control3F
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- F
Implement a program that monitors antibiotic use.
Nutrition and Dietary2F
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Pharmacy Service2D
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- D
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.
Administration2F
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- F
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Resident Rights2D
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Nursing and Physician Services2D
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Freedom from Abuse, Neglect, and Exploitation2D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Inspection history
2025-06-18
5 health deficiencies · 5 fire-safety deficiencies
Top issue: Infection Control (1 deficiency)
2023-09-28
9 health deficiencies · 16 fire-safety deficiencies
Top issue: Administration (2 deficiencies)
2022-10-13
17 health deficiencies · 13 fire-safety deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 5 min of nursing staff time a day, 39 min of it from a registered nurse.
This home
4 h 5 min
Kansas average
4 h 8 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 37% of nursing staff and 0% of registered nurses left in the past year, along with 3 administrators.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$13,287 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2024-04-03 | Fine | $13,287 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.9 pts better | 0.8 | 1.7 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.2 pts worse | 3.2 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine10.2 pts worse | 82.7% | 92.9% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.5 pts better | 96.4% | 94.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury8 pts worse | 12.2% | 4.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms6.6 pts better | 0.0% | 6.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.9 pts worse | 6.7% | 4.8% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication5.1 pts better | 18.3% | 23.4% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication10.7 pts better | 7.0% | 17.7% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened1 pts worse | 15.5% | 14.5% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased20.6 pts worse | 38.0% | 17.4% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder1.4 pts better | 0.0% | 1.4% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection2.5 pts worse | 5.3% | 2.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence3.8 pts better | 17.8% | 21.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers4.7 pts worse | 9.1% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine48.9 pts worse | 28.2% | 77.1% | 82.3% |
·
Who owns and runs it
22 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Cheyenne County Village Inc | 5% Or Greater Direct Ownership Interest · Organization | 100% | 1 facilities |
| Carmichael, Sherry | Corporate Director · Individual | 0% | 1 facilities |
| Cheyenne County Village Inc | Operational/Managerial Control · Organization | 0% | 1 facilities |
| County Of Cheyenne | Adp Of The SNF · Organization | 0% | 1 facilities |
| Grace Team LLC | Operational/Managerial Control · Organization | 0% | 11 facilities |
| Grace Team LLC | Adp Of The SNF · Organization | 0% | 11 facilities |
| Grace, Ryan | Operational/Managerial Control · Individual | 0% | 10 facilities |
| Grace, Ryan | Adp Of The SNF · Individual | 0% | 10 facilities |
| Gt Services LLC | Operational/Managerial Control · Organization | 0% | 4 facilities |
| Gt Services LLC | Adp Of The SNF · Organization | 0% | 4 facilities |
| Houtman, Sara | Corporate Director · Individual | 0% | 1 facilities |
| Huebert, Eric | Operational/Managerial Control · Individual | 0% | 10 facilities |
| Huebert, Eric | Adp Of The SNF · Individual | 0% | 10 facilities |
| Keller, Thomas | Corporate Director · Individual | 0% | 4 facilities |
| Klepper, Rod | Direct Ownership Interest · Individual | 0% | 1 facilities |
| Klepper, Rod | Corporate Officer · Individual | 0% | 1 facilities |
| Licke, Heather | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Licke, Heather | Adp Of The SNF · Individual | 0% | 1 facilities |
| Lohr, Brooke | Corporate Officer · Individual | 0% | 1 facilities |
| Mctague, Daphne | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Mctague, Daphne | Adp Of The SNF · Individual | 0% | 2 facilities |
| Schultz, Eddy | Corporate Director · Individual | 0% | 1 facilities |
·
Fire safety
34 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke11F
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- F
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Gas, Vacuum, and Electrical Systems8F
- E
Have proper medical gas storage and administration areas.
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have proper medical gas storage and administration areas.
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Ensure proper usage of power strips and extension cords.
- E
Have proper medical gas storage and administration areas.
Miscellaneous6F
- F
Have simulated fire drills held at unexpected times.
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- F
Have simulated fire drills held at unexpected times.
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Services3E
- E
Have properly installed electrical wiring and gas equipment.
- E
Have properly installed electrical wiring and gas equipment.
- E
Have properly installed electrical wiring and gas equipment.
Egress3F
- F
Install emergency lighting that can last at least 1 1/2 hours.
- F
Have properly located and lighted "Exit" signs.
- F
Install emergency lighting that can last at least 1 1/2 hours.
Emergency Preparedness2F
- F
Develop and maintain an Emergency Preparedness Program (EP).
- F
Conduct testing and exercise requirements.
Electrical1F
- F
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
·
Other homes nearby
-
Sarah Ann Hester Memorial Home
Benkelman, NE
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 4 h 24 min
- Fines
- $0
-
Topside Manor Inc
Goodland, KS · Grace Team Services
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 4 h 42 min
- Fines
- $49,937
-
Hillcrest Care Center
Wray, CO
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- —
- Fines
- $0