Leisure Homestead At Stafford

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.14 therapist hours per resident per day in 2026Q1 — more than 11% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 37 beds and averages 35.6 residents a day — about 96% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Weekend coverage: total nurse staffing is 2.88 hrs/resident/day on weekends vs 3.73 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 0.43 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 37% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

20 citations, most serious first. The 10 most serious are shown; the remaining 10 are one tap away and print in full.

• Potential for harm · Fcited before2025-08-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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 dirt on the bottom rim of the shelving unit.One red and three white plastic cutting boards were heavily gouged.The area next to the steam table had two shelves which held items such as assorted syrups and breakfast items had littered food debris.Three plastic containers used to store dry cereal had a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-08-20 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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). This deficient practice placed the residents at increased risk for infections. Findings included:- Observed on 08/18/25 at 08:35, R22 was in his recliner in his room with his nebulizer on his overbed table. The nebulizer had fluid in it, and the face mask had a greasy film on it. R22 stated staff did not rinse out his nebulizer after each use and said he did not do it…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-08-20 · tag F0908 — failed to keep essential equipment working — pattern
  Keep all essential equipment working safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. Observed on 08/19/25 at 03:15 PM, the second sit-to-stand had multiple large areas of the foot base with exposed rust, the right resident hand-hold had approximately half the foam missing, exposing metal, and the left hand-hold foam was ripped, exposing metal. During an interview on 08/18/25 at 11:08 AM, Certified Medication Aide (CMA) R and Certified Nurse Aide (CNA) M stated that the sit-to-stand (one) damage had been…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Environmental Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 35 residents, the sample included 12 residents. Based on interview, observation, and record review, the facility failed to inform Resident (R) 29 and/or his representative regarding the risks related to psychotropic (alters mood or thoughts) medications. These practices had the potential to lead to uninformed decisions regarding treatment.Findings included:- Review of the Electronic Health Record (EHR) for R29 included diagnoses of unspecified psychosis not due to a substance or known physiological condition (when a person experiences psychotic symptoms but the specific cause isn't clear, and it's not linked to substance use or a known medical condition), neuroleptic induced parkinsonism (a form of drug-induced parkinsonism that occurs as a side effect of certain medications, particularly those used to treat psychiatric disorders like schizophrenia), extrapyramidal and movement disorder (movement disorders as a result of taking certain medications), schizophrenia (a mental…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0628 — isolated
  Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 35 residents. The sample included 12 residents with one resident reviewed for hospitalization. Based on interview and record review, the facility failed to provide Resident (R) 38 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 and failed to provide a written notification to the resident and/or his representative for the reason of the resident's transfer to the hospital in a language easy to understand. This placed the resident at risk of not understanding bed hold policy or the reason of the transfer. Findings included:- R38's Electronic Medical Record (EMR) revealed a diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R38's EMR documented a Progress Note which noted R38 transferred to the hospital on [DATE].R38's EMR lacked documentation of a bed hold and lacked documentation…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-08-20 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility identified a census of 35 residents. The sample included 12 residents with three residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to provide weekly wound assessments for Resident (R) 1. This deficient practice placed the resident at risk for developing pressure injuries and delayed wound healing. Findings included:- R1's Electronic Health Record (EHR) revealed a diagnosis of Stage 4 (a deep pressure wound that reaches the muscles, ligaments, or even bone) pressure ulcer of the left heel, chronic osteomyelitis (bone infection) of the left foot and ankle, Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) of the right foot, and Stage 2 pressure ulcer of the buttock dated 07/27/25. R1's 06/25/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-08-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  The facility reported a census of 35 residents. The sample included 12 residents, which included one resident reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to provide necessary supervision and assistance required for safe ambulation for Resident (R) 6. This placed R6 at risk for falls and fall-related injuries. Findings included:- Review of the Electronic Health Record (EHR) revealed that R6 included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), other symptoms and signs involving cognitive functions and awareness (difficulties with memory, concentration, decision-making, problem-solving, and understanding, as well as changes in behavior and communication), a need for assistance with personal care (assistance with activities of daily living [ADLs] that an individual is unable to perform independently due to illness, disability, or advanced age), and repeated falls (two or more falls within a specific time frame, typically a year or six months).The 07/23/25 admission Minimum…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-09-21 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. The soiled linen room/sorting room lacked available Personal Protective Equipment (PPE) goggle/face shield for sorting soiled clothing and linens. 2. The laundry processing area had three unsanitizable wired laundry baskets due to split rubber gaskets around the top of the baskets and rust on the wires. One basket had a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-09-21 · tag F0657 — failed to keep the care plan current — pattern
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 33 residents with a sample of 12 residents. Based on observation, interview, and record review, the facility failed to review and revise the care plan with relevant interventions following falls to prevent further falls for four sampled residents (R)16, R10, R32, and failed to revise the care plan for R21, related to compression stockings. Findings included: - Resident (R)16's Physician Orders, dated 09/11/23, included diagnoses of muscle spasms, sprain of the left ankle, left hand pain, rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), left and right shoulder pain, and obesity (severe overweight). The admission Minimum Data Set, (MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status, (BIMS) score of 13, indicating cognitively intact. She required extensive assistance of staff for bed mobility, transfers, toilet use, and walking in the room. The resident used a walker and wheelchair…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2023-09-21 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 33 residents with a sample of 12 residents which included four residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to complete a thorough investigation to determine contributing factors and causes of falls to implement appropriate immediate new interventions following falls for Resident (R)16, R10, R7, and R32. Findings included: - Resident (R)16's Physician Orders, dated 09/11/23, included diagnoses of muscle spasms, sprain of the left ankle, left hand pain, rheumatoid arthritis (a chronic inflammatory disorder affecting many joints, including those in the hands and feet), left and right shoulder pain, and obesity (severe overweight). The admission Minimum Data Set, (MDS) dated [DATE], documented the resident with Brief Interview for Mental Status, score of 13, indicating cognitively intact. She required extensive assistance of staff for bed mobility, transfers, toilet use, and walking in the room. The resident used a walker…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

CMS files one row per role, so the 16 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KS