F0689

L

Failure to Prevent Armed Workplace Violence Between CNAs on Resident Unit

Leawood, Kansas Survey Completed on 02-11-2026

Penalty

Fine: $19,105

Summary

The deficiency involves the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision to prevent accidents, specifically by failing to prevent two CNAs from bringing firearms into the building and engaging in gunfire on a resident unit. On the night of the incident, one CNA (CNA M) walked down the Northeast (NE) corridor, unlocked an exit door, then returned toward the nurses’ station. He reached into his jacket, turned toward the dining room where another CNA (CNA N) was located, and fired multiple shots into the dining room. Video surveillance reviewed by administrative staff showed this sequence of events, including CNA M unlocking the NE corridor door, returning toward the nurses’ station, drawing a gun from his jacket, firing into the dining room, and then fleeing out the NE corridor door.

In response to the gunfire from CNA M, CNA N returned an unknown number of rounds down the East Hall, where nine residents resided. A bullet grazed the wall near the room of one resident (R2), leaving a four- to six-inch graze mark, and a bullet, possibly the same one, struck the doorframe of another resident’s room (R1). Subsequent observation of the East Hall revealed a round indentation on the lower part of R1’s doorframe and a graze mark on the wall near R2’s room. In the dining room across from the East Hall, there were two bullet holes in the window and two to three bullet holes in the wall. Staff on duty reported hearing gunshots and screams, seeing smoke and shell casings near the nurses’ station, and then moving to call 911 and check on residents.

Residents described being awakened and startled by the gunfire. R1, seated in a wheelchair in his room, reported initially thinking the sounds were pots and pans clanging, then realizing they were three to four shots, one of which hit his doorframe; he thought the shooter might be coming into his room for him. R2, also in a wheelchair in his room, stated that the gunshots startled him awake and that he was scared for a few seconds. Staff interviews revealed that earlier in the shift, CNA N felt uneasy about CNA M and went out to his car to retrieve his gun, which he then brought into the facility without reporting his concern to anyone. Another nurse (LN I) and a CNA (CNA O) described an escalating verbal argument between CNA M and CNA N in the dining area, including demeaning and vulgar comments, with CNA M pacing and attempting to leave while CNA N continued to pull him back into the conversation, before CNA M walked down the NE hall, returned, and began firing. The facility’s employee handbook, in effect at the time, prohibited acts or threats of violence and the possession of weapons of any kind on the property, but both CNAs nonetheless possessed guns inside the facility and engaged in gunfire on the East unit, placing residents in immediate jeopardy.