Deficiency Index

Leisure Homestead at Stafford

Stafford, Kansas · CCN 175530

14 surveys since 2012, 1 of them producing a finding at harm level or worse.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
79
Surveys
14
Harm or worse
1
Immediate jeopardy
0
The record, 2012–2025
’12’15’20’25
No harm recordedHarm or worseNot surveyed
Harm or worse1

Findings where a surveyor recorded actual harm to a resident.

Beyond CMS’s monthly file11/14

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
37
Ownership
Non profit - Corporation
Chain
Independent
County
Stafford · rural
Medicare-certified since
2012

CMS ratings

Overall
3
Health inspection
4
Staffing
1
Quality measures
2

CMS’s own Five-Star ratings.

Compared with similar facilities

Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.

Weighted by harm level, against 83 not-for-profit facilities with fewer than 66 beds in Kansas.

Last survey on record

Aug 20, 2025

446 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Annual nurse turnover36.7%43.9%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD1260.0%E420.0%F315.0%
No harm, potential for minimalA—B—C15.0%
CMS’s current file: 20 of the 79 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F8803×

    Provide and implement an infection prevention and control program.

  • F6892×

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • F8122×

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  • F5521×

    Ensure that residents are fully informed and understand their health status, care and treatments.

  • F6281×

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

In the surveyor’s words

From the most serious findings on record at Leisure Homestead at Stafford, in the surveyor’s own words.

  • No harm, potential for more than minimal, widespreadF812Aug 20, 2025

    The facility reported a census of 35 residents, one kitchen and one kitchenette. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for foodborne bacteria. This placed the residents at risk of food-borne illnesses.Findings included:- During an initial tour of the kitchen on 08/18/25 at 11:03 AM, the following areas of concern were noted: The reach-in refrigerator/freezer unit had seven of eight wired shelves with large areas of missing protective and plastic coating, making them unsanitizable.The two-door reach-in freezer had eight wired shelves with large areas of missing protective and plastic coating, making them unsanitizable.The dry storage rack by the back door had a heavy build-up of… […]

  • No harm, potential for more than minimal, widespreadF880Sep 21, 2023

    The facility reported a census of 33 residents. Based on observation, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent cross contamination and the spread of infection in the laundry and throughout the facility. Furthermore, the facility failed to perform required hand hygiene between residents during the delivery of clean linen and passing ice water. Additionally, the facility failed to provide appropriate respiratory care in maintaining respiratory equipment to prevent the spread of infection for three residents (R)9, R31, and R7. Findings included: - On 09/21/23 at 11:06 AM, the laundry tour with Laundry/Housekeeping staff I, and Assistant Maintenance Supervisor J, revealed the following concerns: 1. […]

  • No harm, potential for more than minimal, widespreadF812Dec 8, 2021

    The facility reported a census of 37 residents with one main kitchen, which prepared and served food for all residents. Based on observation, interview, and record review the facility failed to handle and store food in accordance with professional standards for food service safety when dietary staff did not prepare food for storage or date and store foods in a sanitary manner. Findings included: - On 12/06/21 at 07:40 AM initial tour of main kitchen revealed the following: In the refrigerator the following foods were not dated: shredded cabbage, green peppers, shredded lettuce, cauliflower, and broccoli, there was also a container of carrot salad, a thawed frozen TV dinner, and a plate of brownies all opened and undated. […]

  • No harm, potential for more than minimal, patternF880Aug 20, 2025

    The facility reported a census of 35 residents. The sample included 12 residents. Based on interviews, record reviews and observation, the facility staff failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R)1 who had a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag). The facility failed to follow adequate hand hygiene and infection control practices related to catheter bags and tubing as well as sanitary storage of nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs). […]

  • No harm, potential for more than minimal, patternF908Aug 20, 2025

    The facility reported a census of 35 residents. The sample included 12 residents. Based on interviews, record review, and observation, the facility failed to ensure residents had safe and properly maintained resident care equipment. This deficient practice placed the residents at risk for infection and decreased comfort.Findings included:- Observed on 08/18/25 at 11:08 AM, the leg pad on one sit-to-stand lift (medical devices designed to assist individuals with limited mobility in transitioning from a seated to a standing position) had a large, missing chunk from the leg pad, the foam resident grips were missing pieces, and there was exposed rust on the legs. […]

Read 21 findings in full →The most serious and the most recent: 21 of 79 on record.

Every survey on record

FindingsAt actual harm or above

  • Aug 20, 2025Standard and complaint8 findings
  • Sep 21, 2023Standard6 findings
  • Jul 15, 2022Complaint4 findings
  • Dec 8, 2021Complaint6 findings
  • Jul 30, 2021Complaint5 findings
  • Feb 18, 2020Standard2 findings
  • Feb 28, 2019Standard and complaint5 findings
  • Mar 22, 2018Standard and complaint6 findings
Show the 6 earlier surveys
  • Nov 29, 2016Complaint4 findings
  • Jan 11, 2016Standard4 findings
  • Dec 3, 2014Standard1 finding
  • Sep 25, 2014Standard20 findings · 1 harm
  • Jun 18, 2013—1 finding
  • Apr 2, 2012—7 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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