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The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 30th out of 133 homes in Kansas.| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 37m per day | ▼ 14% State avg: 43m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 33m per day | ▼ 18% State avg: 40m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 3h 4m per day | ▲ 14% State avg: 2h 41m per day · National avg: 2h 20m per day |
|
Total Nursing (Weekend)
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 3h 52m per day | ▲ 8% State avg: 3h 35m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 4m per day | ▲ 100% State avg: 2m per day · National avg: 4m per day |
|
RN (Weekend)
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 33m per day | ▲ 10% State avg: 30m per day · National avg: 28m per day |
Most residents typically stay for a few weeks or months before returning home or moving on.
88% of new residents, usually for short-term rehab.
4% of new residents, often for short stays.
8% of new residents, often for long-term daily care.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #110 / 134Payroll — State benchmarkedThis home is ranked 110th out of 134 homes in Kansas.Shows total annual staff payroll benchmarked to the Kansas average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.Click the rank badge to see the full State ranking.Click here to see the full State ranking.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
Lower than the Kansas average: 79.5%Cheyenne County Village, Inc is administrated by Simon Madondo.
In Kansas, the Department for Aging and Disability Services, Survey and Certification Commission performs the unannounced inspections required for facility licensing and federal certification.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Kansas state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies are formal regulatory issues recorded during state inspections.
| Metric | This Facility | KS Average | vs. KS Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 284 | 100 | This facility has 184% more total deficiencies than a typical Kansas nursing home (284 vs. KS avg 100). Click this badge to view the full Kansas ranking.↑ 184% worse |
|
Deficiencies per year
Average deficiencies per year since 2001.
| 11.4 | 4 | This facility has 185% more deficiencies per year than a typical Kansas nursing home (11.4 vs. KS avg 4). Click this badge to view the full Kansas ranking.↑ 185% worse |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
The most recent inspection on December 10, 2025, found the facility in compliance with all regulations and no new deficiencies. Prior inspections in late 2025 noted deficiencies related to failure to post survey reports publicly, incomplete negotiated service agreements, and unpaid licensing fees, but these issues were corrected by the December revisit. Earlier inspections identified recurring themes including care planning deficiencies, catheter and infection control issues, medication storage problems, and food safety concerns. Complaint investigations over the years included substantiated cases involving inadequate wound care leading to resident harm and delayed physician notifications, some resulting in immediate jeopardy findings and enforcement actions such as payment denials. The facility’s inspection history shows periods of significant deficiencies followed by corrective actions and improvements, with the most recent reports indicating resolution of prior issues.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsKansas average 4.5
Last Health inspection on Apr 2024
Kansas average 26.9
Kansas average 6.07
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
29 of 31 citations resulted from standard inspections; and 2 of 31 resulted from complaint investigations.
11% worse than Kansas averageKansas average: 0.9
11% worse than Kansas averageKansas average: 0.9
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Cheyenne County Village, Inc is located in ST. FRANCIS, Kansas.
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0.0 miles from city center
Estimated distance in miles from St. Francis's city center to Cheyenne County Village, Inc's address, calculated via Google Maps.
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Reporting period: April 1 – June 30, 2025 (Q2 2025). Source: CMS Payroll-Based Journal report.
0% compared with Kansas average
0% compared with Kansas average
This data comes from the CMS Payroll-Based Journal report covering April 1 – June 30, 2025.
Manages medical care and health needs.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
10.6 hoursThis role is partially covered by contractors.
Assists with medical care and medications.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
10.2 hoursThis role is partially covered by contractors.
Helps with daily care and mobility.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.3 hoursThis role is partially covered by contractors.
This data comes from the CMS Payroll-Based Journal report covering April 1 – June 30, 2025.
Total hours from contractors
1,828 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering April 1 – June 30, 2025.
| Certified Nursing Assistant | 14 | 10 | 24 | 4,781 | 91 | 100% | 7.3 |
| Medication Aide/Technician | 5 | 2 | 7 | 1,734 | 91 | 100% | 9.9 |
| Licensed Practical Nurse | 2 | 1 | 3 | 1,432 | 86 | 95% | 10.2 |
| Registered Nurse | 3 | 1 | 4 | 754 | 62 | 68% | 10.6 |
| Nurse Practitioner | 0 | 1 | 1 | 512 | 64 | 70% | 8 |
| Dietitian | 2 | 0 | 2 | 487 | 66 | 73% | 4.9 |
| Dental Services Staff | 1 | 0 | 1 | 301 | 46 | 51% | 6.5 |
| Administrator | 0 | 1 | 1 | 240 | 30 | 33% | 8 |
| Physical Therapy Assistant | 0 | 1 | 1 | 176 | 56 | 62% | 3.1 |
| Speech Language Pathologist | 0 | 1 | 1 | 165 | 49 | 54% | 3.4 |
| Respiratory Therapy Technician | 0 | 1 | 1 | 111 | 19 | 21% | 5.8 |
| Qualified Social Worker | 0 | 1 | 1 | 85 | 53 | 58% | 1.6 |
| RN Director of Nursing | 2 | 0 | 2 | 53 | 6 | 7% | 8.8 |
| Occupational Therapy Aide | 0 | 1 | 1 | 16 | 3 | 3% | 5.3 |
| Occupational Therapy Assistant | 0 | 1 | 1 | 12 | 3 | 3% | 3.8 |
| Medical Director | 0 | 1 | 1 | 3 | 3 | 3% | 1 |
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
24Residents meet regularly to discuss policies, care quality, and activities
State-approved Nurse Aide Training and Competency Evaluation Program on-site
Part of a Continuing Care Retirement Community offering multiple care levels
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
17.9
70% worse than Kansas averageKansas average: 10.5
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
28.5
38% worse than Kansas averageKansas average: 20.7
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
33.3%
75% worse than Kansas averageKansas average: 19.0%
Percent of long-stay residents whose ability to move independently worsened
26.7%
38% worse than Kansas averageKansas average: 19.4%
Percent of low risk long-stay residents who lose control of their bowels or bladder
25.4%
7% worse than Kansas averageKansas average: 23.8%
Percent of long-stay residents experiencing one or more falls with major injury
11.8%
169% worse than Kansas averageKansas average: 4.4%
Percent of long-stay high risk residents with pressure ulcers
10.0%
116% worse than Kansas averageKansas average: 4.6%
Percent of long-stay residents with a urinary tract infection
1.1%
65% better than Kansas averageKansas average: 3.1%
Percent of long-stay residents who lose too much weight
7.4%
46% worse than Kansas averageKansas average: 5.1%
Percent of long-stay residents who have depressive symptoms
1.3%
75% better than Kansas averageKansas average: 5.2%
Percent of long-stay residents who received an antipsychotic medication
2.2%
87% better than Kansas averageKansas average: 16.9%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
89.3%
In line with Kansas averageKansas average: 91.9%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
92.6%
In line with Kansas averageKansas average: 95.5%
Number of hospitalizations per 1,000 long-stay resident days.
1.58
14% better than Kansas averageKansas average: 1.84
Number of outpatient emergency department visits per 1,000 long-stay resident days.
2.09
In line with Kansas averageKansas average: 2.16
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
51.2%
32% worse than Kansas averageKansas average: 75.6%
Percent of short-stay residents who newly received an antipsychotic medication
19.1%
779% worse than Kansas averageKansas average: 2.2%
Percentage of SNF residents who experience falls with major injury during their stay.
4.0%
419% worse than Kansas averageKansas average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
42.9%
20% worse than Kansas averageKansas average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
44.1%
13% worse than Kansas averageKansas average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database (Data as of Jan 2026)
70% lower than Kansas averageKansas average: $44K
59% fewer fines than Kansas averageKansas average: 2.4
Serious action where Medicare and/or Medicaid temporarily stops payments for new residents until issues are fixed.
0
100% fewer payment denials than Kansas averageKansas average: 0.3
Penalties are imposed by CMS for violations of federal nursing home regulations.
1 penalty in the past 3 years
Apr 3, 2024 · $13K
Fines imposed for noncompliance, which can be assessed per day or per instance of violation.
Apr 3, 2024Last updated: Jan 2026
| Brookdale Rosehill |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence.
N Nursing | Shawnee | 148 | 76.2% | -4% | 4.27 | +53% | -8% | $0 | 35 | 8.8 | - | 69 | A+ | 54 | Mary Patchett | $14.8M | $7.5M | 50.7% | 175478 | ||||
| Cheyenne County Village, Inc |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | St. Francis | 30 | 83.7% | +5% | 5.40 | -24% | +17% | $13.3k | 31 | 7.8 | 2 | 22 | - | 55 | Cheyenne County Village Inc | $4.2M | $2.2M | 52.5% | 175347 |
Historical financial and operational data for Cheyenne County Village, Inc based on CMS SNF Cost Reports.
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The legal owner and operator of Cheyenne County Village, Inc is Cheyenne County.
Cheyenne County Village, Inc has a walk score of 55. Moderately walkable. Some errands can be accomplished on foot, with a mix of nearby amenities.
According to KS state health department records, Cheyenne County Village, Inc's license number is 175347.
Cheyenne County Village, Inc's occupancy is 30%.
Simon Madondo is the administrator of Cheyenne County Village, Inc.
Cheyenne County Village, Inc has 30 beds.
Yes — there is 1 photo of Cheyenne County Village, Inc in the photo gallery on this page.
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