Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cheyenne County Village Inc during CMS and state inspections, most recent first.
The facility did not provide consistent care for a resident admitted with a Stage 3 pressure ulcer on the coccyx. Despite an initial wound assessment, the facility failed to regularly monitor the wound, resulting in its progression to Stage 4 with exposed bone and uncontrollable bleeding. Additionally, the facility did not adhere to the wound consultant's orders for daily dressing changes, and there were instances where proper wound care supplies were unavailable. This lack of consistent wound assessments, measurements, and adherence to treatment protocols contributed to the deterioration of the resident's condition.
A resident with multiple diagnoses, including a Stage 3 pressure ulcer, did not receive appropriate pain management during dressing changes. Despite documented pain and discomfort, the facility failed to administer pain medication before or after the procedures, as noted in the medical records and confirmed by staff interviews. This resulted in untreated pain and impacted the resident's well-being.
Inconsistent Pressure Ulcer Management Leading to Worsening Condition
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the worsening of pressure ulcers for Resident (R) 1, who was admitted with a Stage 3 pressure ulcer on the coccyx. Despite the initial wound assessment, the facility did not consistently monitor the wound, leading to the worsening of the ulcer over time. The lack of consistent wound assessments, measurements, and identification of signs of infection resulted in the progression of the pressure ulcer to a Stage 4 with exposed bone, ultimately leading to uncontrollable bleeding and the resident's transfer to a higher level of care. Additionally, the facility did not effectively involve the physician when needed, as evidenced by the failure to address the wound consultant's orders for daily wound dressing changes. There were multiple instances where the wound dressing changes were not performed as ordered, with staff failing to ensure the proper wound care supplies were available. This lack of adherence to treatment protocols and failure to follow through on physician orders contributed to the deterioration of R1's wound and overall health status.
Failure to Provide Pain Management During Dressing Changes
Penalty
Summary
The facility failed to provide appropriate pain management for a resident (R1) who had documented pain and demonstrated signs of discomfort during pressure ulcer dressing changes. R1 had multiple diagnoses, including a Stage 3 pressure ulcer, congestive heart failure, metastatic lung cancer, hypertension, and hyperlipidemia. Despite these conditions and the presence of a painful pressure ulcer, R1 did not receive scheduled or as-needed pain medication, nor any non-medication interventions for pain, as documented in the Minimum Data Set (MDS) and other medical records. The facility's records show that R1 consistently reported pain during dressing changes, yet pain medication was not administered before or after these procedures on numerous occasions from September to October 2023 and beyond. The Wound Daily Observation Notes repeatedly documented R1's pain and discomfort during dressing changes, with descriptions of the wound being saturated with drainage, the presence of slough, and the wound bed being red and undermined. Despite these observations, the Medication Administration Records (MAR) for September, October, and November 2023 show that R1 was not given any pain medication before or after the dressing changes. This lack of pain management was corroborated by interviews with facility staff, who confirmed that R1 often denied pain but exhibited signs of discomfort and agitation during dressing changes. The facility's Pain Policy, revised in October 2022, outlines the importance of assessing and managing pain based on professional standards of practice and the resident's needs. However, the facility failed to adhere to this policy, resulting in untreated pain for R1. The administrative nurse acknowledged that not all interventions to prevent R1's pressure ulcer from worsening were in place upon admission and was unaware that pain medication was not administered before or after dressing changes. This deficient practice led to R1 experiencing unnecessary pain and discomfort, impacting his psychosocial well-being.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near St Francis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sarah Ann Hester Memorial Home | 23.8 mi | ★★★★★ | 7 | 0 |
| Topside Manor Inc | 28.6 mi | ★★★★★ | 0 | 0 |
| Hillcrest Care Center | 29.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.