Cycle 1
Health 2025-08-20 · Fire 2025-08-20
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Stafford, KS
Leisure Homestead At Stafford
3-star overall rating with 4-star inspections with 8 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
405 Grand Avenue, Stafford, KS
(620) 234-5208
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
37
Certified beds
Average residents
33
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2012-07-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.47
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.00
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
4.01
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,913
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.99
Composite VBP score used to determine payment impact.
Payment multiplier
1.0005
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
5.79
Baseline 43.59% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 1.42
Adjusted total nurse staffing
3.60
Baseline 4.27 hours · Performance 4.10 hours · Measure score 3.60 · Achievement 3.60 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 4 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 7.14% |
8.2%
1.1 pts worse
|
Numerator 3 · Denominator 42 |
| Staff flu vaccination coverage | 7.32% |
42%
34.7 pts worse
|
Numerator 3 · Denominator 41 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.6 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.2
0.9 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.6% |
91.8%
0.8 pts better
|
93.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.2% · Q2 96.6% · Q3 96.6% · Q4 90.0% · 4Q avg 92.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
4.4%
1.1 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.4% · Q3 0.0% · Q4 3.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
5.6%
3.8 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 0.0% · Q4 3.4% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.0%
5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
23.2%
8.6 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 12.5% · Q3 13.6% · Q4 17.4% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.8% |
19.8%
9 pts better
|
16.7%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.4% |
18.4%
12 pts worse
|
16.3%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 36.0% |
18.8%
17.2 pts worse
|
14.9%
21.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 31.8% · Q3 55.0% · Q4 35.0% · 4Q avg 36.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.8%
0.1 pts better
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 3.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.6% |
3.1%
3.5 pts worse
|
1.7%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 10.3% · Q3 6.9% · Q4 3.3% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.4% |
23.2%
3.2 pts worse
|
19.8%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.0% · Q2 21.9% · Q3 16.0% · Q4 29.4% · 4Q avg 26.4% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
4.6%
3 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 11.1% · Q3 9.1% · Q4 6.6% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.5% |
75.6%
15.1 pts worse
|
81.7%
21.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 60.5% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-21 · Fire 2023-09-21
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-12-08 · Fire 2021-12-08
6 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-11-19
F · Potential for more than minimal harm
2025-08-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-11-19
F · Potential for more than minimal harm
2025-08-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-24
F · Potential for more than minimal harm
2025-08-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-11-19
F · Potential for more than minimal harm
2025-08-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-24
F · Potential for more than minimal harm
2025-08-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-11-19
F · Potential for more than minimal harm
2025-08-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-11-19
F · Potential for more than minimal harm
2025-08-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-11-19
F · Potential for more than minimal harm
2025-08-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-11-19
F · Potential for more than minimal harm
2025-08-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-11-19
E · Potential for more than minimal harm
2025-08-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-08-20
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-10-24
F · Potential for more than minimal harm
2023-09-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-13
F · Potential for more than minimal harm
2023-09-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-13
F · Potential for more than minimal harm
2023-09-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-13
E · Potential for more than minimal harm
2023-09-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-13
F · Potential for more than minimal harm
2021-12-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-01-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-27
E · Potential for more than minimal harm
2025-08-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-27
E · Potential for more than minimal harm
2025-08-20
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-09-27
D · Potential for more than minimal harm
2025-08-20
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-09-27
D · Potential for more than minimal harm
2025-08-20
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-27
D · Potential for more than minimal harm
2025-08-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-27
D · Potential for more than minimal harm
2025-08-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-27
C · Minimal harm
2025-08-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-09-27
F · Potential for more than minimal harm
2023-09-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-21
E · Potential for more than minimal harm
2023-09-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-21
E · Potential for more than minimal harm
2023-09-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-21
D · Potential for more than minimal harm
2023-09-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-21
D · Potential for more than minimal harm
2023-09-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-21
D · Potential for more than minimal harm
2023-09-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-10-21
F · Potential for more than minimal harm
2021-12-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-01-22
D · Potential for more than minimal harm
2021-12-08
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-01-22
D · Potential for more than minimal harm
2021-12-08
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-01-22
D · Potential for more than minimal harm
2021-12-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-01-22
D · Potential for more than minimal harm
2021-12-08
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-01-22
D · Potential for more than minimal harm
2021-12-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-22
Penalties and ownership
What sits behind the stars
Ownership
Leisure Homestead Association
5% Or Greater Direct Ownership Interest · Organization
Brensing, Tamara
Corporate Director · Individual
Farmer, Fredrick
Operational/Managerial Control · Individual
Gillespie, Jennifer
Operational/Managerial Control · Individual
Gillespie, Jennifer
Corporate Officer · Individual
Hildebrand, Don
Operational/Managerial Control · Individual
Hildebrand, Don
Corporate Director · Individual
Leisure Homestead Association
Operational/Managerial Control · Organization
Meschberger, Anita
Operational/Managerial Control · Individual
Meschberger, Anita
Corporate Officer · Individual
Younie, James
Operational/Managerial Control · Individual
Younie, James
Corporate Director · Individual
Zimmerman, Nancy
Operational/Managerial Control · Individual
Zimmerman, Nancy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Grand Plains Skilled Nursing By Americare
Pratt, KS
2-star overall rating with 2-star inspections with abuse icon flag with 8 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
#2
Pratt Health And Rehab
Pratt, KS
3-star overall rating with 3-star inspections with $22,925 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Hilltop Manor Nursing Center
Cunningham, KS
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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