Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

CHEYENNE COUNTY VILLAGE INC

ST FRANCIS, KS · 30 certified beds · Last Life Safety survey September 28, 2023

CMS Certification Number 175347 · first certified June 1995

Ownership

Operated by GRACE TEAM SERVICES · Non profit - Corporation

Ownership changed November 1, 2018 (change of ownership)from THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within KS

37 citations — more than 80% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 16 citations; the earlier surveys in the window averaged 10.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (May 2025 to August 2025), and past the point by which nine in ten KS facilities have been surveyed. This facility’s last Life Safety survey was September 2023. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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10 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

2 of the 37 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 37 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	37
Median facility in KS	27
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
July 28, 2021	8
October 13, 2022	13
September 28, 2023	16

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	3	2023-09-28
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	3	2023-09-28
K-0712	Have simulated fire drills held at unexpected times.	3	2023-09-28
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2023-09-28
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	3	2023-09-28
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	2	2023-09-28
K-0363	Install corridor and hallway doors that block smoke.	2	2022-10-13
K-0511	Have properly installed electrical wiring and gas equipment.	2	2023-09-28

What the citations cover

Citations by CMS category

Smoke Deficiencies 14
Gas, Vacuum, and Electrical Systems Deficiencies 8
Miscellaneous Deficiencies 6
Egress Deficiencies 4
Other 5

Citations by CMS category
Category	Citations
Smoke Deficiencies	14
Gas, Vacuum, and Electrical Systems Deficiencies	8
Miscellaneous Deficiencies	6
Egress Deficiencies	4
Services Deficiencies	2
Emergency Preparedness Deficiencies	2
Electrical Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 28, 2023 — 16 citations

Citations issued on September 28, 2023
Tag	What the surveyor checks	Status
E-0004	Develop and maintain an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (November 18, 2023)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (November 18, 2023)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (November 18, 2023)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (November 18, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (November 18, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (November 18, 2023)
K-0362	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.	Deficient, Provider has date of correction (November 18, 2023)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (November 18, 2023)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (November 18, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (November 18, 2023)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (November 18, 2023)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (November 18, 2023)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (November 18, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (November 18, 2023)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (November 18, 2023)
K-0926	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Deficient, Provider has date of correction (November 18, 2023)

October 13, 2022 — 13 citations

Citations issued on October 13, 2022
Tag	What the surveyor checks	Status
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (December 19, 2022)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (December 19, 2022)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (December 19, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (December 19, 2022)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (December 19, 2022)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (December 19, 2022)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (December 19, 2022)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (December 19, 2022)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (December 19, 2022)
K-0901	Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.	Deficient, Provider has date of correction (December 19, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (December 19, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (December 19, 2022)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (December 19, 2022)

July 28, 2021 — 8 citations

Citations issued on July 28, 2021
Tag	What the surveyor checks	Status
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (September 23, 2021)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (September 23, 2021)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (September 23, 2021)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (September 23, 2021)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (September 23, 2021)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (September 23, 2021)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (September 23, 2021)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (September 23, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.