2/5
CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
2/5
CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
Cheyenne County Village is a county-governed, nonprofit nursing home operating a 30-bed campus in St. Francis, Kansas. Led by administrator Simon Madondo, the facility provides short-term skilled nursing alongside longer-term assisted and independent living options. It accepts Medicare, Medicaid, and private pay solutions. Because the home currently operates at an occupancy rate of approximately 30 percent, the typical environment is quiet, and the average length of stay for residents is 278 days.
The care structure delivers an average of 5 hours and 24 minutes of direct nursing care per resident each day, utilizing a team of registered nurses, licensed practical nurses, and certified nursing assistants. Situated in a rural area, the neighborhood retains a moderate level of walkability for local services. Regarding regulatory oversight, state evaluations have noted historical patterns concerning care planning, infection control, medication systems, and kitchen safety protocols, though recent reviews demonstrate intervals of compliance.
Families looking into local care options can contact the administrative office directly to discuss current room availability, specific rehabilitation programs, or the operational systems in place to maintain regulatory 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.
Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| 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.
| 42m per day | ■ Avg 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.
| 29m per day | ▼ 29% 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.
| 2h 56m per day | ▲ 9% State avg: 2h 41m per day · National avg: 2h 20m per day |
|
Weekend Total Nursing
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 32m per day | ■ Avg 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.
| 3m per day | ▲ 73% State avg: 2m per day · National avg: 4m per day |
|
Weekend RN
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.
| 39m per day | ▲ 30% State avg: 30m per day · National avg: 28m per day |
Average number of days residents stay at this facility, based on CMS cost report data. Shorter stays often reflect post-acute or rehab care; longer stays reflect long-term care.
Lower than the Kansas average: 79.5%Cheyenne County Village, Inc is administered 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, deficiency, 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
| This Facility | KS Average | vs. KS Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 306 | 100 | This facility has 206% more total deficiencies than a typical Kansas assisted living residence (306 vs. KS avg 100).↑ 206% worse |
|
Deficiencies per year
Average deficiencies per year since 2001.
| 12.2 | 4 | This facility has 205% more deficiencies per year than a typical Kansas assisted living residence (12.2 vs. KS avg 4).↑ 205% worse |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
State average N/A
Last Health inspection on Apr 2024
State average N/A
State average N/A
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.
In line with State averageState average: N/A
In line with State averageState average: N/A
Corrected
Corrected
Corrected
Corrected
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
0% compared with State averageState average ratio: 0 : 0
0% compared with State averageState average: 0 hours
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
All 3 RN Staff are full-time employees. No contractors work on this role.
3
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.6 hoursAssists with medical care and medications.
All 1 LPN Staff are full-time employees. No contractors work on this role.
1
Average shift length. Calculated as total hours divided by days worked and average staff per day.
11.3 hoursHelps with daily care and mobility.
22 total: 12 full-time employees and 10 contractors.
22
Average shift length. Calculated as total hours divided by days worked and average staff per day.
7.7 hours
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Total hours from contractors
2,570 contractor hours this quarter
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 12 | 10 | 22 | 4,686 | 92 | 100% | 7.7 |
| Medication Aide/Technician | 5 | 5 | 10 | 2,132 | 92 | 100% | 10.2 |
| Registered Nurse | 3 | 0 | 3 | 1,154 | 90 | 98% | 9.6 |
| Administrator | 0 | 2 | 2 | 911 | 64 | 70% | 7.7 |
| Licensed Practical Nurse | 1 | 0 | 1 | 586 | 52 | 57% | 11.3 |
| RN Director of Nursing | 1 | 0 | 1 | 521 | 60 | 65% | 8.7 |
| Nurse Practitioner | 0 | 1 | 1 | 488 | 61 | 66% | 8 |
| Physical Therapy Assistant | 0 | 1 | 1 | 268 | 61 | 66% | 4.4 |
| Dental Services Staff | 1 | 0 | 1 | 152 | 22 | 24% | 6.9 |
| Speech Language Pathologist | 0 | 2 | 2 | 146 | 42 | 46% | 3.5 |
| Qualified Social Worker | 0 | 1 | 1 | 140 | 55 | 60% | 2.5 |
| Respiratory Therapy Technician | 0 | 1 | 1 | 134 | 20 | 22% | 6.7 |
| Occupational Therapy Aide | 0 | 1 | 1 | 17 | 3 | 3% | 5.6 |
| Occupational Therapy Assistant | 0 | 1 | 1 | 13 | 3 | 3% | 4.3 |
| Medical Director | 0 | 1 | 1 | 3 | 3 | 3% | 1 |
Includes penalties issued in 2024
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 State averageState average: $44K
59% fewer fines than State averageState 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 State averageState 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
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 State averageState average: 10.5
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
28.5
38% worse than State averageState 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 State averageState average: 19.0%
Percent of long-stay residents whose ability to move independently worsened
26.7%
38% worse than State averageState average: 19.4%
Percent of low risk long-stay residents who lose control of their bowels or bladder
25.4%
7% worse than State averageState average: 23.8%
Percent of long-stay residents experiencing one or more falls with major injury
11.8%
169% worse than State averageState average: 4.4%
Percent of long-stay high risk residents with pressure ulcers
10.0%
116% worse than State averageState average: 4.6%
Percent of long-stay residents with a urinary tract infection
1.1%
65% better than State averageState average: 3.1%
Percent of long-stay residents who lose too much weight
7.4%
46% worse than State averageState average: 5.1%
Percent of long-stay residents who have depressive symptoms
1.3%
75% better than State averageState average: 5.2%
Percent of long-stay residents who received an antipsychotic medication
2.2%
87% better than State averageState average: 16.9%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
89.3%
In line with State averageState average: 91.9%
Percent of long-stay residents assessed and appropriately given the seasonal influenza vaccine
92.6%
In line with State averageState average: 95.5%
Number of hospitalizations per 1,000 long-stay resident days.
1.58
14% better than State averageState average: 1.84
Number of outpatient emergency department visits per 1,000 long-stay resident days.
2.09
In line with State averageState 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 State averageState average: 75.6%
Percent of short-stay residents who newly received an antipsychotic medication
19.1%
779% worse than State averageState average: 2.2%
Percentage of SNF residents who experience falls with major injury during their stay.
4.0%
419% worse than State averageState average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
42.9%
20% worse than State averageState average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
44.1%
13% worse than State averageState average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
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.
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.
Historical financial and operational data for Cheyenne County Village, Inc from 2011–2023, based on CMS SNF Cost Reports.
Key figures below are for fiscal year ending in 12/2023.
Based on CMS SNF Cost Report for fiscal year ending in 12/2023.
Net patient revenue — what the home actually collects for resident care, after contractual allowances, bad debt and discounts are subtracted from its gross charges (CMS cost report, Worksheet G-3). It covers resident care only; money the home earns from other sources is shown separately as "Other income."
Net patient income: net patient revenue minus the home's total operating expenses. A positive figure means it earns more from resident care than it spends to deliver it; a negative figure means the opposite. It excludes non-operating "other income."
Net patient revenue — what the home actually collects for resident care, after contractual allowances, bad debt and discounts are subtracted from its gross charges (CMS cost report, Worksheet G-3). It covers resident care only; money the home earns from other sources is shown separately as "Other income."
Net patient income: net patient revenue minus the home's total operating expenses. A positive figure means it earns more from resident care than it spends to deliver it; a negative figure means the opposite. It excludes non-operating "other income."
Money the home earns outside of resident care — such as investments, grants, rentals and other non-operating sources (CMS cost report, Worksheet G-3). It is tracked separately from net patient revenue: it is not part of that figure, and it is not included in net patient income.
Staff salaries plus wage-related costs — benefits such as payroll taxes, health insurance and retirement — from the home's own accounting records (CMS cost report, Worksheet A). Contract or agency labor is counted separately, under other operating costs.
Payroll as a share of revenue: staff salaries and wage-related benefits divided by net patient revenue. A higher figure means more of each revenue dollar goes to staff pay.
Everything it costs to run the home apart from payroll — food, utilities, supplies, maintenance, contract labor and administration. Calculated as total operating expense minus payroll (staff salaries and wage-related benefits).
The home's total operating expense for the year — all the costs of running it, salaries included (CMS cost report, Worksheet G-3).
Most residents typically stay for a few weeks or months before returning home or moving on.
Most new residents arrive under Medicare (88% of admissions), and a typical Medicare stay runs around 1 - 2 months.
Coverage residents most often arrive under.
Coverage residents most often leave under.
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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Cheyenne County Village, Inc is legally operated by Cheyenne County, and administered by Simon Madondo.
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%.
Cheyenne County Village, Inc is registered as a non-profit in KS.
Simon Madondo is the administrator of Cheyenne County Village, Inc.
Cheyenne County Village, Inc has 30 beds.
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