Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Leisure Homestead At Stafford during CMS and state inspections, most recent first.
Surveyors found that food was not prepared and served under sanitary conditions due to unsanitizable refrigerator and freezer shelves, dirty storage racks, heavily gouged cutting boards, food debris on shelves, and dusty cereal containers. Dietary staff confirmed these areas needed cleaning, and facility policies for regular cleaning and sanitizing were not followed.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Surveyors observed that two sit-to-stand lifts had significant damage, including missing foam grips, exposed rust, and exposed metal, with one lift's issues reported to administration a month prior and the other not reported at all. Maintenance staff, responsible for monthly checks, was unaware of the full extent of the damage, despite facility policy requiring prompt reporting and regular inspection of equipment.
A resident with multiple psychiatric and neurological conditions was given an increased dosage and frequency of clonazepam without documented evidence that the resident or their representative was informed or provided consent for the change. Staff interviews indicated a belief that updated consent was unnecessary for dosage changes, and the facility's policy required comprehensive assessment and documentation, which was not met in this case.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Surveyors found that necessary interventions, assessments, and monitoring were not consistently provided, resulting in the occurrence and worsening of pressure ulcers.
A resident with severe cognitive impairment, dementia, and a history of falls was repeatedly observed ambulating and wandering without staff assistance, despite care plans and physician orders requiring ambulation with assistance only. Multiple staff failed to intervene or follow established orders and facility policy, resulting in a lack of necessary supervision and increased risk for falls.
A resident with diabetes mellitus was transferred to the hospital without receiving written notice about the bed hold policy or a written explanation for the transfer in an understandable language, as required by facility policy. Staff confirmed that these notifications were not provided or documented.
The facility did not accurately post daily nurse staffing information as required, as the actual hours worked by nursing staff were not completed on the daily staffing sheets for 35 residents. This was confirmed by an administrative nurse and was not in accordance with the facility's policy mandating the posting of shift data and total hours worked.
Unsanitary Food Storage and Preparation Areas
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchen and kitchenette, including reach-in refrigerator and freezer shelves with large areas of missing protective and plastic coating, rendering them unsanitizable. The dry storage rack by the back door had a heavy build-up of dirt on the bottom rim, and several plastic cutting boards were heavily gouged. Additionally, shelves near the steam table holding assorted syrups and breakfast items were littered with food debris, and three plastic containers used for dry cereal had a build-up of dust on the lids. Dietary staff confirmed that these areas required cleaning. Facility policies required regular cleaning, rinsing, and sanitizing of these areas, but these procedures were not followed, resulting in the failure to prepare and serve food under sanitary conditions.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of an effective program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Maintain Safe and Functional Resident Lifts
Penalty
Summary
The facility failed to ensure that essential resident care equipment, specifically two sit-to-stand lifts, was maintained in a safe and functional condition. Observations revealed that one lift had a large missing chunk from the leg pad, missing foam grips, and exposed rust on the legs. The second lift had multiple large areas of exposed rust on the foot base, and both hand-hold foams were either missing or ripped, exposing metal. These deficiencies were directly observed by surveyors during their visit. Interviews with staff indicated that the damage to the first sit-to-stand lift had been reported to administration at least a month prior, while the damage to the second lift had not been reported at all. Maintenance staff reported conducting monthly equipment checks but was unaware of the full extent of the damage to the first lift and completely unaware of the issues with the second lift. Facility policy required that malfunctions or needed repairs be reported and that lifts be inspected monthly by maintenance, but these procedures were not effectively followed.
Failure to Obtain Informed Consent for Psychotropic Medication Dosage Change
Penalty
Summary
The facility failed to inform a resident and/or the resident's representative about the risks associated with psychotropic medications, specifically regarding a change in the dosage and frequency of clonazepam. The resident had a history of multiple psychiatric and neurological diagnoses, including unspecified psychosis, neuroleptic-induced parkinsonism, extrapyramidal and movement disorders, schizophrenia, schizoaffective disorder, and anxiety disorder. The resident's cognitive status varied over time, with documented severe cognitive impairment at one point and cognitive intactness at another. The care plan indicated the use of antipsychotic and antianxiety medications, and interventions included administering medications as ordered, monitoring for side effects, and communicating with the family and physician about ongoing medication needs. A review of the electronic health record showed that while there was a signed psychotropic consent for clonazepam at a lower dose, there was no evidence that the resident or representative was informed or provided consent for a subsequent increase in the medication's dosage and frequency. Interviews with administrative nursing staff revealed a belief that updated consent was not necessary for dosage changes if the medication itself remained the same, and that informed consent could be obtained verbally rather than in writing. The facility's policy stated that psychotropic medications should be administered based on comprehensive assessment and with proper documentation, but the required education and consent for the medication change were not present in the record.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents were not consistently receiving necessary interventions to manage existing pressure ulcers or to prevent new ones from forming. The lack of proper assessment, monitoring, and timely intervention contributed to the occurrence and worsening of pressure ulcers among residents.
Failure to Provide Required Supervision and Assistance for Resident Ambulation
Penalty
Summary
A deficiency occurred when staff failed to provide the necessary supervision and assistance required for safe ambulation for a resident with severe cognitive impairment, dementia, a history of repeated falls, and wandering behaviors. The resident's care plan and physician's orders specified that ambulation should only occur with staff assistance due to high fall risk, impaired cognition, incontinence, and use of high-risk medications. Despite these documented needs and orders, the resident was repeatedly observed ambulating and wandering in the hallways and common areas without any staff assistance. Multiple staff members were present during these observations but did not intervene or provide the required assistance. Interviews with facility staff revealed a lack of awareness and adherence to the resident's ambulation orders. A certified medication aide incorrectly stated that the resident did not have ambulation orders and was allowed to ambulate freely, while a licensed nurse initially stated the resident could ambulate alone before confirming the existence of the assistance-only order. Administrative staff confirmed that staff were expected to follow provider orders and the resident care plan. The facility's own policy required supervision and interventions to minimize significant injuries, but these were not implemented for this resident, placing her at risk for falls and related injuries.
Failure to Provide Required Written Bed Hold and Transfer Notifications
Penalty
Summary
The facility failed to provide a resident and/or their representative with a written notice specifying the duration and cost of the bed hold policy at the time of the resident's transfer to the hospital. Additionally, the facility did not provide a written notification to the resident and/or their representative explaining the reason for the transfer in a language that was easy to understand. These requirements are outlined in the facility's own Discharge/Transfer policy, which mandates written notification prior to transfer or discharge. The deficiency was identified through review of the electronic medical record (EMR) for a resident with a diagnosis of diabetes mellitus who was transferred to the hospital. The EMR lacked documentation of both the bed hold policy notification and the written explanation for the transfer. An administrative nurse confirmed that staff did not provide the required written notifications at the time of the transfer.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to display accurate, publicly accessible, and identifiable daily nurse staffing information for its 35 residents. Review of the facility's Daily Staffing Sheets over a period from early July to mid-August revealed that the actual hours worked by nursing staff were not completed on these sheets. This omission was confirmed by an administrative nurse, who acknowledged that the required information was missing. The facility's own policy, revised in January 2023, mandates the posting of individual shift data and total hours worked each day by both licensed and unlicensed nursing staff responsible for resident care.
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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 Stafford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand Plains Skilled Nursing By Americare | 21.8 mi | ★★★★★ | 3 | 0 |
| Pratt Health And Rehab | 22 mi | ★★★★★ | 6 | 0 |
| Hilltop Manor Nursing Center | 23.6 mi | ★★★★★ | 22 | 1 |
| Sterling Village | 27.5 mi | ★★★★★ | 0 | 0 |
| Azria Health Great Bend | 30.1 mi | ★★★★★ | 9 | 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.