Inspection Reports for Leisure Homestead at Stafford
405 GRAND AVENUE, STAFFORD, KS, 67578-2009
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 29, 2015, found that all previously cited deficiencies had been corrected. Prior to this, inspections in late 2014 identified multiple deficiencies related to food preparation and storage, infection control, chemical safety, and environmental hazards, including unsecured chemicals and allowing pets in dining areas. Enforcement actions included denial of payment for new Medicare/Medicaid admissions and a recommendation for termination of the provider agreement, though no fines or license suspensions were listed in the available reports. Complaint investigations were not noted in the reports, and most complaints appear to have been unsubstantiated. The facility’s inspection history shows improvement over time, with corrective actions implemented and deficiencies resolved by the most recent revisit.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
125% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
32 residents
Based on a November 2014 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 29, 2015
Visit Reason
This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies identified by regulation numbers F0323, F0364, F0371, F0441, F0465, and F0520 were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 6
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Dec 3, 2014
Visit Reason
The visit was a first revisit conducted on December 3, 2014, to verify that the facility had achieved and maintained compliance with Federal requirements following the September 25, 2014 Health survey.
Findings
The revisit found the most serious deficiencies to be 'F' level deficiencies, resulting in denial of payment for new Medicare/Medicaid admissions effective December 25, 2014, and a recommendation for termination of the provider agreement on March 25, 2014.
Deficiencies (1)
Deficiencies cited during the revisit with the most serious being 'F' level deficiencies
Report Facts
Denial of Payment effective date: Dec 25, 2014
Provider agreement termination date: Mar 25, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Gillespie | Administrator | Named as facility administrator in relation to the inspection and findings |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 3, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously cited with various regulation numbers were corrected as of the revisit date, December 3, 2014.
Report Facts
Deficiencies corrected: 10
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 6
Date: Nov 25, 2014
Visit Reason
The inspection was conducted as a revisit to a prior non-compliance survey (MDP212) to assess correction of previously cited deficiencies.
Findings
The facility was found non-compliant in multiple areas including failure to secure chemicals behind locked doors, improper preparation of pureed food not following dietician-approved recipes, unsanitary food storage with undated open food items, ineffective infection control practices due to improper use of cleaning chemicals, unclean food preparation equipment, and allowing a resident's pet dog in the dining room during meal times. The Quality Assessment and Assurance (QAA) committee failed to develop and implement plans of action to address these deficiencies.
Deficiencies (6)
Failure to secure chemicals behind locked doors, exposing 12 cognitively impaired and independently mobile residents to accident hazards.
Failure to prepare pureed food as recommended in the dietician approved recipe, affecting 4 residents receiving pureed diets.
Failure to store food under sanitary conditions with undated open food items and dented cans in dry storage and walk-in refrigerator.
Failure to provide a safe and sanitary environment by using ineffective cleaning chemicals and improper cleaning practices.
Failure to provide a safe, functional, sanitary, and comfortable environment by not thoroughly cleaning food preparation equipment and allowing a resident's pet dog in the dining room during meal times.
Failure of the Quality Assessment and Assurance (QAA) committee to develop and implement appropriate plans of action to correct identified quality deficiencies.
Report Facts
Residents cognitively impaired and independently mobile: 12
Residents receiving pureed diets: 4
Facility census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping staff C | Reported cleaning practices and use of unlabeled cleaning solutions | |
| Dietary staff F | Observed preparing pureed food without following recipe | |
| Dietary staff G | Interviewed regarding food preparation and storage practices | |
| Maintenance staff E | Reported on locked doors for chemical storage | |
| Administrative nurse A | Provided expectations for food preparation and chemical storage | |
| Administrative staff B | Reported on chemical storage, cleaning products, and QAA committee issues | |
| Consultant H | Provided guidance on pureed food preparation |
Inspection Report
Plan of Correction
Deficiencies: 14
Date: Oct 7, 2014
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The Plan of Correction outlines corrective actions for multiple deficiencies including Medicare non-coverage notices, incident reporting, abuse policy updates, comprehensive resident assessments, care plan revisions, skin assessments, kitchen door security, food preparation, infection control, call light maintenance, and facility cleanliness.
Deficiencies (14)
Liability notice form revised to include QIO contact information and monitoring of Medicare payment eligibility and notices.
Incident reports and resident injuries reviewed for reporting; mandatory in-service on abuse, neglect, and exploitation.
Abuse policy updated with reporting requirements; reference checks on new hires implemented.
Comprehensive assessments done on admission and as needed; care plans developed and updated accordingly.
Care plan revised for resident toileting assistance and continence status.
Initial/temporary care plans developed upon admission with shift report implementation.
Skin assessments and Braden Scale done on admission, quarterly, or with changes; wound care protocols followed.
Kitchen doors kept closed and locked with key access; signage posted to protect residents from hazards.
Pureed foods prepared as directed to conserve nutritive value; dietary consultant oversight.
Food items discarded by expiration date; food prep equipment sanitized with chemical effectiveness monitored.
Facility assists with dental appointments and transportation; dental services contracted every six months.
Staff educated on chemical wet times; C-difficile killing chemical obtained; isolation policies followed.
Call lights checked and repaired as needed; maintenance and monitoring protocols established.
Kitchen maintenance including replacement of broken light shield, cleaning of equipment, and pet policy enforcement.
Report Facts
Plan of Correction completion dates: Oct 24, 2014
Dental service frequency: 6
Call light checks frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Younie | Administrator | Administrator who submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 29, 2014
Visit Reason
The licensure survey was conducted as part of the facility's licensing process to assess compliance with regulatory requirements.
Findings
The survey resulted in a finding of no deficiency citations, indicating full compliance with applicable standards.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 25, 2014
Visit Reason
A Health survey was conducted by the Kansas Department for Aging and Disability Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be a 'G' level related to noncompliance with F314, Pressure Ulcers. Enforcement remedies including denial of payment for new Medicare admissions were imposed due to failure to achieve substantial compliance.
Deficiencies (1)
Noncompliance with F314, Pressure Ulcers
Report Facts
Months until recommended termination: 6
Civil Money Penalty minimum amount: 5000
Effective date of denial of payment: Dec 25, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Gillespie | Administrator | Named as facility administrator in relation to the inspection. |
| Irina Strakhova | Enforcement Coordinator | Contact person for questions concerning the instructions contained in the letter. |
Inspection Report
Annual Inspection
Census: 32
Deficiencies: 14
Date: Sep 25, 2014
Visit Reason
The inspection was a health resurvey of the facility to assess compliance with regulatory requirements including resident rights, abuse prevention, care planning, pressure ulcer prevention, infection control, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to provide complete liability notices, failure to report and investigate abuse allegations timely, inadequate employee screening, incomplete and untimely care planning, development of avoidable pressure ulcers, unsafe environment hazards including hot water and chemical access, unsanitary food preparation and storage, missing resident call light functionality, and allowing pets in the dining area during meal service.
Deficiencies (14)
Failed to include the name and phone number of the QIO for residents to file an immediate appeal on liability notices.
Failed to immediately report, investigate, and report results of an injury of unknown origin (swollen lip) for a resident.
Failed to adequately screen newly hired employees by completing reference checks and update abuse policy with current reporting requirements.
Failed to develop a comprehensive care plan with measurable goals and specific interventions for pressure ulcer treatment and prevention.
Failed to update and revise plan of care to reflect changes in urinary incontinence status for a resident.
Failed to develop an initial/temporary care plan upon admission for a resident.
Failed to prevent development of avoidable pressure ulcers after admission for a resident.
Failed to ensure resident environment remained free of accident hazards by propping kitchen doors open allowing resident access to hot water over 150°F and hazardous chemicals, and allowing access to an unalarmed exit door.
Failed to conserve nutritive value of pureed pork by thinning with water instead of nutritional liquid.
Failed to store and prepare food under sanitary conditions including expired foods, unclean kitchen appliances, and improper sanitation of food processor.
Failed to promptly refer a resident to the dentist after loss of a partial dental plate for at least four months.
Failed to establish and maintain an infection control program by not following manufacturer instructions for chemical wet times and lacking chemicals effective against C-difficile spores.
Failed to maintain resident call lights in working order for multiple resident rooms.
Failed to provide a safe and sanitary environment related to kitchen cleanliness and allowing two dogs to roam the dining room during meal service, including one dog defecating on the floor.
Report Facts
Residents sampled: 22
Facility census: 32
Pressure ulcers developed: 5
Temperature: 151.2
Expired yogurt: 2
Expired cranberry sauce containers: 5
Inspection Report
Life Safety
Deficiencies: 1
Date: Mar 18, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
Most serious deficiencies found to be 'F' level deficiencies, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy.
Report Facts
Effective date for denial of payments: Jun 18, 2014
Provider agreement termination date: Sep 18, 2014
IDR request deadline: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Gillespie | Administrator | Named as facility administrator in relation to the survey |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Jul 1, 2013
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiency identified under regulation 483.65 with ID prefix F0441 was corrected as of 07/01/2013.
Deficiencies (1)
Deficiency under regulation 483.65 identified by prefix F0441
Report Facts
Deficiency correction date: Jul 1, 2013
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 2
Date: Jun 18, 2013
Visit Reason
The inspection was a Health Resurvey to assess compliance with infection control and other regulatory requirements.
Findings
The facility failed to maintain proper infection control practices, specifically failing to cleanse glucometers before and after use for several residents and improperly storing oxygen administration equipment, which could lead to the spread of infection.
Deficiencies (2)
Failure to cleanse glucometer machine before and after blood sugar checks for residents #7, #17, and #26.
Improper storage of oxygen tubing and nasal cannulas for residents #9 and #20, not placed in protective coverings.
Report Facts
Census: 29
Sample size: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Observed performing blood sugar checks without cleansing glucometer | |
| Nurse A | Verified glucometer cleaning procedures and oxygen equipment storage requirements |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Apr 30, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All deficiencies previously cited under various regulations were corrected as of the revisit date, April 30, 2012.
Deficiencies (7)
Deficiency under regulation 483.13(c)
Deficiency under regulation 483.20(g)-(j)
Deficiency under regulation 483.25
Deficiency under regulation 483.25(d)
Deficiency under regulation 483.25(h)
Deficiency under regulation 483.35(i)
Deficiency under regulation 483.65
Report Facts
Deficiencies corrected: 7
Inspection Report
Re-Inspection
Census: 29
Deficiencies: 7
Date: Apr 2, 2012
Visit Reason
The inspection was a Health Resurvey (re-inspection) to evaluate compliance with previously cited deficiencies and overall facility regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to conduct criminal record checks for new staff, inaccurate resident assessments, inadequate care and services for residents, failure to prevent urinary tract infections, unsafe environmental hazards, unsanitary food preparation practices, and poor infection control procedures.
Deficiencies (7)
Failure to conduct criminal record checks for 1 of 5 staff members hired since the last survey.
Failure to accurately assess resident status for 2 of 9 sampled residents.
Failure to provide necessary care and services to maintain highest well-being for 1 of 9 sampled residents.
Failure to provide appropriate toileting services to prevent urinary tract infection for 1 resident.
Failure to adequately assess a large gap in a positioning rail for 1 resident.
Failure to prepare, distribute, and serve food under sanitary conditions; dietary staff did not properly cover hair.
Failure to maintain infection control practices including hand washing and proper handling of soiled linens.
Report Facts
Census: 29
Sample size: 9
Employees hired since last survey: 5
Residents reviewed for incontinence: 1
Gap in positioning rail: 20
Gap in positioning rail: 8
Time resident remained in recliner without toileting: 5.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse B | Nurse | Verified resident care and assessment deficiencies, infection control issues |
| Nurse F | Nurse | Verified resident leaning and toileting issues |
| Dietary Staff A | Dietary Staff | Observed not properly covering hair while preparing and serving food |
| Dietary Staff C | Dietary Staff | Verified dietary hair covering policy |
| Nurse Aide E | Certified Nurse Aide | Observed carrying soiled linens improperly |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: N093002 POC 41SU11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses deficiencies related to cleaning and disinfection of glucometers and proper storage of oxygen concentrators and related equipment to prevent contamination.
Deficiencies (2)
Failure to ensure proper cleaning and disinfection of glucometers.
Failure to ensure proper storage of oxygen tubing, masks, and canulas to prevent contamination.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| James Younie | Asst. Admin. | Submitted the Plan of Correction to KDADS. |
| Irina Strakhova | Added and modified the Plan of Correction. |
Inspection Report
Plan of Correction
Census: 120
Deficiencies: 6
Date: N093002 POC MPD212
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection of the facility.
Findings
The Plan of Correction addresses multiple deficiencies including unsecured chemical storage, improper preparation of pureed foods, inadequate food storage labeling and sanitation, improper chemical labeling and use, and cleaning schedule compliance. Corrective actions include installation of self-locking door knobs, staff training, competency checks, and ongoing monitoring by supervisors and consultants.
Deficiencies (6)
Janitor closet doors and chemical storage doors were not secured properly.
Pureed foods were not prepared as directed on the menu and recipe.
Food storage areas/refrigerators/freezers lacked proper labeling, dating, and sanitation.
Housekeeping carts contained chemicals in unlabeled spray bottles and wet times were not updated.
Refrigerator and freezer doors, food processing machine, and stove burners were not cleaned properly.
Quality Assurance and Assessment Committee deficiencies review and corrective action planning.
Report Facts
Census: 120
Competency and compliance check dates: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Younie | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 8
Date: N093002 POC TBGL11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The Plan of Correction addresses multiple deficiencies including incomplete criminal background checks for employees, inadequate restorative and rehabilitative services documentation, improper use of wrist splints, toileting plans, positioning of residents, dietary staff hygiene practices, and handling of soiled linens. The facility outlines corrective actions and monitoring plans to achieve substantial compliance by specified dates.
Deficiencies (8)
Failure to obtain and maintain criminal background check results for dietary staff.
Deficient restorative and rehabilitative services documentation and monitoring for residents #4 and #20.
Improper use and non-compliance with wrist splint for resident #4.
Resident #15 positioning and need for specialized chair assessment.
Inadequate individualized toileting plans for resident #6 and others.
Bed rail use and positioning aids for resident #20 requiring monitoring.
Dietary staff not consistently wearing hairnets as required.
Improper handling of soiled linens and lack of warm wash cloths for residents.
Report Facts
Complete date: Apr 18, 2012
Complete date: Apr 3, 2012
Complete date: Apr 30, 2012
Complete date: Apr 3, 2012
Complete date: Apr 10, 2012
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