Cheyenne County Village INC
820 S Denison Street, St Francis, KS 67756
Cheyenne County Village INC is a nursing home in St Francis, Kansas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 3 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (785) 332-2531
- Last standard health inspection
- June 18, 2025 (1 year ago)
- Certified beds
- 30
- Residents per day, on average
- 28
- Ownership type
- Non profit - Corporation
- Legal business name
- Cheyenne County Village INC
- Chain
- Grace Team Services
- Takes part in
- Medicare and Medicaid
More health citations than the Kansas average (31 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of May 27, 2026
Ownership
CMS lists this home under a new chain.
CMS update of April 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of June 25, 2025
Fine
CMS changed the fine from April 3, 2024 from $16,594 to $13,286.
5 citations
Health inspection on June 18, 2025
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 30, 2025.
CMS has cited this home for F0812 2 times since 2023.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 30, 2025.
CMS has cited this home for F0657 2 times since 2022.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on July 30, 2025.
CMS has cited this home for F0690 3 times since 2022.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 30, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 30, 2025.
CMS has cited this home for F0880 2 times since 2023.
5 citations
Fire safety inspection on June 18, 2025
CMS lists this as a standard inspection.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 26, 2025.
CMS has cited this home for K0353 3 times since 2022.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on August 26, 2025.
CMS has cited this home for K0712 3 times since 2022.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on August 26, 2025.
CMS has cited this home for K0372 3 times since 2022.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on August 26, 2025.
CMS has cited this home for K0511 3 times since 2022.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on August 26, 2025.
CMS has cited this home for K0923 3 times since 2022.
CMS update of April 30, 2025
Fine
CMS changed the fine from April 3, 2024 from $20,440 to $16,594.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.6 to 4.1 hours per resident per day.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
2 citations
Health inspection on April 3, 2024
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
69 of 296 Kansas homes (23%) got a citation at the immediate jeopardy level in 2024.
Citation F0686. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 18, 2024.
Citation F0697. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on April 18, 2024.
Fine
April 3, 2024 (2 years ago)
CMS fine of $13,287 on April 3, 2024.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 2 of 5.
9 citations
Health inspection on September 28, 2023
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on October 25, 2023.
Citation F0851. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on October 25, 2023.
Citation F0868. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
CMS lists it as corrected on October 25, 2023.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on October 25, 2023.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on October 25, 2023.
CMS has cited this home for F0656 2 times since 2022.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on October 25, 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on October 25, 2023.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on October 25, 2023.
CMS has cited this home for F0726 2 times since 2022.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 25, 2023.
16 citations
Fire safety inspection on September 28, 2023
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on November 18, 2023.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on November 18, 2023.
CMS has cited this home for K0291 2 times since 2022.
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on November 18, 2023.
Citation K0321. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on November 18, 2023.
CMS has cited this home for K0321 2 times since 2022.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on November 18, 2023.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on November 18, 2023.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on November 18, 2023.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on November 18, 2023.
CMS has cited this home for K0761 2 times since 2022.
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on November 18, 2023.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on November 18, 2023.
CMS has cited this home for K0918 2 times since 2022.
Citation K0923. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on November 18, 2023.
Citation K0926. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
CMS lists it as corrected on November 18, 2023.
Citation K0362. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
CMS lists it as corrected on November 18, 2023.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on November 18, 2023.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on November 18, 2023.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on November 18, 2023.
15 citations
Health inspection on October 13, 2022
CMS lists this as a standard inspection.
Citation F0881. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement a program that monitors antibiotic use.
CMS lists it as corrected on November 25, 2022.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on November 25, 2022.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on November 25, 2022.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on November 25, 2022.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on November 25, 2022.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on November 25, 2022.
Citation F0660. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Plan the resident's discharge to meet the resident's goals and needs.
CMS lists it as corrected on November 25, 2022.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on November 25, 2022.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on November 25, 2022.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on November 25, 2022.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 25, 2022.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on November 25, 2022.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 25, 2022.
Citation F0744. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on November 25, 2022.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on November 25, 2022.
13 citations
Fire safety inspection on October 13, 2022
CMS lists this as a standard inspection.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on December 19, 2022.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on December 19, 2022.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on December 19, 2022.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on December 19, 2022.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on December 19, 2022.
Citation K0901. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
CMS lists it as corrected on December 19, 2022.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on December 19, 2022.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on December 19, 2022.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on December 19, 2022.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on December 19, 2022.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on December 19, 2022.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on December 19, 2022.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on December 19, 2022.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CHEYENNE COUNTY VILLAGE INC5% or greater direct ownership interest · 100% · since 11/01/2018
- KLEPPER, RODDirect ownership interest · not applicable · since 11/01/2018
- CHEYENNE COUNTY VILLAGE INCOperational/managerial control · not applicable · since 11/01/2018
- GRACE TEAM LLCOperational/managerial control · not applicable · since 11/01/2018
- GT SERVICES LLCOperational/managerial control · not applicable · since 11/01/2019
- GRACE, RYANOperational/managerial control · not applicable · since 11/01/2018
- HUEBERT, ERICOperational/managerial control · not applicable · since 10/18/2018
- LICKE, HEATHEROperational/managerial control · not applicable · since 11/01/2018
- MCTAGUE, DAPHNEOperational/managerial control · not applicable · since 02/01/2021
Questions
When was Cheyenne County Village INC last inspected?
CMS lists June 18, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Cheyenne County Village INC have?
CMS lists 31 health citations since October 13, 2022. CMS also calls these deficiencies.
Has Cheyenne County Village INC been fined?
CMS lists 1 fine in the past three years, $13,287 in total.
What is the CMS star rating of Cheyenne County Village INC?
Its CMS overall star rating is 3 of 5.
Is Cheyenne County Village INC a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.