01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2023-09-28 | 9 | 2023-09-28 | 16 |
| Cycle 2 | 2022-10-13 | 15 | 2022-10-13 | 13 |
| Cycle 3 | 2021-07-28 | 7 | 2021-07-28 | 8 |
CMS CCN 1753472026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Cheyenne County Village Inc
820 S Denison Street · St Francis, KS 67756 · Cheyenne County
Certified beds30CMS provider file
Recent citation rows68current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
68 rows in the current release
2 rows carry G–L scope/severity codes; 1 carry J–L. 18 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2024-04-03 · HEALTHF0686Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-04-18 · complaint2024-04-03 · HEALTHF0697Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-04-18 · complaint2023-09-28 · FIREE0004Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-28 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-28 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-28 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-28 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-28 · HEALTHF0726Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-28 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-28 · HEALTHF0851Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-28 · HEALTHF0868Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-28 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2023-10-252023-09-28 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-28 · FIREK0293Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-28 · FIREK0321Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-28 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-28 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-28 · FIREK0362Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-28 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-28 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-28 · FIREK0712Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-28 · FIREK0741Severity D · isolated; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-28 · FIREK0761Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Correction field: Deficient, Provider has date of correction · 2023-11-182023-09-28 · FIREK0914Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Correction field: Deficient, Provider has date of correction · 2023-11-1803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-04-03 | Fine | $13,287 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CHEYENNE COUNTY VILLAGE INCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 11/01/2018
- KLEPPER, RODIndividual · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 11/01/2018
- CARMICHAEL, SHERRYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2018
- HOUTMAN, SARAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2018
- KELLER, THOMASIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2018
- SCHULTZ, EDDYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/01/2018
- KLEPPER, RODIndividual · CORPORATE OFFICERNOT APPLICABLE · since 11/01/2018
- LOHR, BROOKEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2021
- CHEYENNE COUNTY VILLAGE INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2018
- GRACE TEAM LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2018
- GT SERVICES LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2019
- GRACE, RYANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2018
- HUEBERT, ERICIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/18/2018
- LICKE, HEATHERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2018
- MCTAGUE, DAPHNEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2021
- COUNTY OF CHEYENNEOrganization · ADP OF THE SNFNOT APPLICABLE · since 10/22/2018
- GRACE TEAM LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 06/10/2025
- GT SERVICES LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 08/06/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.91per resident day
RN hours0.68per resident day
Weekend nurse hours3.55per resident day
Staff turnover39.3%CMS reported field
06 / LOCAL RECORDS
Open the Kansas ledger →Other published facilities nearby
No second facility in the same city met the directory rule.