Below 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 The Healthcare Resort Of Leawood - Iron Horse Hlth during CMS and state inspections, most recent first.
The facility failed to prevent two CNAs from bringing firearms into the building and engaging in gunfire on a resident unit, resulting in bullets traveling down a resident hallway and striking a doorframe and wall near occupied rooms. One CNA unlocked an exit door, returned toward the nurses’ station, drew a gun from his jacket, and fired multiple shots into the dining room at another CNA, who then returned fire down the hall where multiple residents resided. Staff reported hearing gunshots, seeing shell casings and smoke near the nurses’ station, and then calling 911 and checking on residents, while two residents in wheelchairs described being awakened and startled by the shots. Interviews indicated that one CNA had earlier felt uneasy about the other and retrieved a gun from his car without reporting his concern, and that an escalating argument with demeaning and vulgar comments preceded the shooting, despite an employee handbook that prohibited workplace violence and weapons on the premises.
A CNA did not have a required annual performance evaluation completed, as confirmed by record review and staff interview. Facility policy mandates yearly evaluations to identify employee strengths and training needs, but documentation for this CNA was missing.
Surveyors found that dietary staff did not wear hairnets, and multiple food items in the kitchen and walk-in refrigerator were not labeled or dated. The convection oven was dirty and had a bucket on the floor catching water from a broken pipe, and the facility could not provide a policy for foodborne illness or food storage.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report notes that safety standards were not met and supervision was lacking, but does not provide further specifics.
Surveyors found two unlocked treatment carts containing medical ointments and wound cleansers in separate units, as well as improperly labeled and expired tuberculin serum vials in a medication storage refrigerator. Nursing staff confirmed that carts should be locked when not in use, and facility policy required all medications and biologicals to be secured.
Surveyors found that clean linens were improperly stored on a PPE cart, soiled linens were left on the floor, and respiratory equipment such as a nebulizer mask and nasal cannula were not stored in a sanitary manner. Additionally, a nurse failed to use a barrier when placing an Accu-Check machine on various surfaces. Staff interviews confirmed these actions were not in line with the facility's infection control policies.
The facility did not obtain or document consent or declination for the PCV20 pneumococcal vaccine for two residents, and there was no evidence that the vaccine was offered or previously administered. An administrative nurse was unable to confirm which immunizations were offered, and the facility lacked a policy for immunizations.
A resident with muscle weakness, cognitive impairment, and a history of falls was found to have her call light placed out of reach while in bed, despite care plan instructions and facility policy requiring it to be accessible at all times. Staff interviews confirmed the expectation for call lights to be within reach, but observations showed this was not followed, resulting in a deficiency in accommodating the resident's needs.
A resident with multiple complex medical needs was discharged without a required summary of her stay or care provided. Despite the care plan and nursing notes indicating significant ADL assistance and ongoing skilled services, the medical record lacked a discharge summary, which staff confirmed was their responsibility to complete.
A resident with dementia, cognitive communication disorder, muscle weakness, and diabetes required varying levels of staff assistance for ADLs, as indicated by assessments. However, the care plan did not document the resident's current level of functioning or the specific assistance needed for tasks such as bathing, dressing, and mobility. Staff interviews confirmed that this information should be included in care plans, but it was missing in this case.
A resident with CHF and multiple comorbidities did not have daily and weekly weights obtained and documented as ordered by the physician. Staff interviews confirmed that the process for ensuring weights were taken and recorded was not followed, resulting in a lack of required documentation in the MAR, TAR, and EMR.
A resident with impaired mobility and incontinence, identified as at risk for pressure ulcers, did not have a physician-ordered pressure-reducing cushion in their wheelchair. Despite care plan documentation and staff acknowledgment of the need for such devices, repeated observations showed the cushion was not in place, and staff were unclear about their responsibilities regarding pressure-reducing devices.
A resident with multiple medical conditions and a physician order for nebulizer treatments was observed to have their nebulizer mask left on the bedside table instead of being stored in a clean, dated plastic bag as described by staff. The care plan lacked instructions for nebulizer use or mask storage, and the facility did not provide a policy for proper storage, resulting in unsanitary respiratory care practices.
A deficiency was identified when laboratory records in a resident's medical file were found to be incomplete and lacking required dates.
A resident receiving hospice care, with multiple chronic conditions and significant ADL needs, did not have a coordinated plan of care between the facility and hospice services. Staff relied on a separate hospice binder and verbal communication for updates, and key hospice information was not integrated into the facility's care plan, contrary to facility policy and staff expectations.
Failure to Prevent Armed Workplace Violence Between CNAs on Resident Unit
Penalty
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.
Removal Plan
- The facility began staff education on workplace violence, reporting protocols, security, anti-harassment and anti-retaliation protections, and technology and social media controls (education ongoing).
- The facility contracted with a security agency for a nighttime security guard.
- The facility notified the residents' representatives of the incident.
- The facility had a psychologist visit with residents possibly affected by the incident.
Annual Performance Evaluation Not Completed for CNA
Penalty
Summary
The facility failed to complete the required annual performance evaluation for one of five reviewed Certified Nurse Aides (CNA), specifically for a CNA hired on 10/11/23. During a review of performance evaluation and in-service training records, it was found that no yearly performance evaluation was available for this CNA when requested. An administrative nurse confirmed that the evaluation had not been completed, despite facility policy requiring annual performance reviews for all employees to identify strengths, goals, and training needs. This deficiency was identified through record review and staff interview.
Failure to Maintain Sanitary Food Storage and Preparation Practices
Penalty
Summary
Surveyors observed multiple failures to follow sanitary dietary standards in the facility's kitchen and kitchenettes. Dietary staff were seen working without hairnets, and several food items in the walk-in refrigerator, including hot dogs, hamburgers, cut-up watermelon, lettuce, and corn salad, were found covered but not labeled or dated. In the walk-in freezer, French-fried potatoes were stored in an unlabeled and undated canister. The top of the convection oven was dirty and cluttered with black gloves and dirty pan cover sheets, and a white plastic bucket was placed on the floor to catch dirty water from a broken pipe above the oven. The facility was unable to provide a policy for foodborne illness or food storage when requested.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the actions or inactions of staff, or the condition of residents at the time, are not provided in the report.
Failure to Secure Treatment Carts and Properly Label Medication
Penalty
Summary
Surveyors observed that two treatment carts in separate units were left unlocked, one in the back nurses' station of the Hallbrook unit and another in the hallway of the Bridgewood unit. Both carts contained medical ointments and wound cleansers. Additionally, in the medication storage room on the Hallbrook unit, a refrigerator inspection revealed two vials of tuberculin serum, one of which was opened without any dates indicating when it was opened or when it should expire, and the other had been opened and was past its 30-day expiration date. Interviews with nursing staff confirmed that carts were expected to be locked when not in use and that staff were responsible for securing carts and patient information when stepping away. The facility's policy required all medications and biologicals to remain locked and secured to prevent tampering or exposure.
Infection Control Deficiencies in Linen and Equipment Handling
Penalty
Summary
Surveyors identified multiple infection control deficiencies during their review of the facility. Clean linens, including towels, washcloths, and a bed sheet, were observed placed on top of a personal protective equipment (PPE) cart in the hallway, rather than being stored in a sanitary manner. In one instance, soiled linen was found on the floor of a resident's room. Additionally, respiratory equipment such as a nebulizer mask and nasal oxygen tubing were not stored properly; the nebulizer mask was left on a bedside table and the nasal cannula was thrown on top of an oxygen canister at the bottom of a resident's bed, rather than being kept in a clean, dated plastic bag as required by facility policy. Further deficiencies were observed in the handling of blood glucose monitoring equipment. A licensed nurse was seen placing the Accu-Check machine directly onto various surfaces, including a medication cart, a shower room counter, and the arm of a Broda chair, without using a barrier as required. Staff interviews confirmed that these practices were inconsistent with facility infection control policies, which mandate the use of barriers for equipment and proper storage of linens and respiratory devices to prevent contamination.
Failure to Document and Offer Pneumococcal Vaccinations and Lack of Immunization Policy
Penalty
Summary
The facility failed to obtain consent or declination for the Pneumococcal Conjugate Vaccine (PCV20) for two residents, despite reviewing their immunization status as part of a sample of five residents. For one resident, the clinical record showed declinations for PCV13 and PPSV23, but lacked documentation that PCV20 was offered, declined, or previously administered. For another resident, records indicated administration of PPSV23 and PCV13, but again lacked documentation regarding PCV20 being offered, declined, or historically administered. Additionally, an administrative nurse was unable to confirm which immunizations were offered at the facility, and the facility did not provide a policy for immunizations.
Failure to Ensure Call Light Accessibility for Resident with High Fall Risk
Penalty
Summary
A deficiency occurred when staff failed to ensure a resident had access to her call light, which was required for her to communicate her needs. The resident had multiple medical diagnoses, including muscle weakness, overactive bladder, a need for assistance with personal care, a history of falling, and a cognitive communication disorder. Her care plan specifically instructed staff to keep the call light within reach at all times due to her high risk for falls and need for substantial to maximal assistance with activities of daily living. Despite these documented needs and instructions, observations showed that the resident's soft-touch call light was placed on a bedside table across the room, out of her reach, while she was in bed on multiple occasions. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that the expectation was for call lights to be within reach of residents at all times and checked each shift. The facility's Fall Management System policy also required appropriate equipment and interventions to ensure resident safety and prevent falls. The failure to follow these protocols and care plan instructions resulted in the resident being unable to communicate her needs, constituting a deficiency in reasonably accommodating her needs and preferences.
Failure to Document Resident Discharge Summary
Penalty
Summary
The facility failed to provide a final summary of a resident's status at discharge, as required. The resident in question had multiple diagnoses, including infection and inflammatory reaction due to a knee prosthesis, MRSA, pain, cognitive decline, major depressive disorder, and dysphagia. Documentation showed the resident required significant assistance with activities of daily living (ADLs) such as eating, oral hygiene, toileting, transfers, and bed mobility. The care plan indicated ongoing skilled services to help the resident regain strength and return home, with identified risks including further ADL decline, falls, incontinence, skin breakdown, and pain. On the day of discharge, the resident's husband arrived to take her home, and nursing staff notified the physician of the discharge. However, the medical record did not contain a summary of the resident's stay or a recompilation of her care, as required by facility policy. Interviews with nursing staff confirmed that it was the responsibility of the nurse in charge, or the DON if not completed, to document this summary, but it was not done in this case.
Failure to Document Resident's Required ADL Assistance in Care Plan
Penalty
Summary
The facility failed to identify and document the specific level of care assistance required for activities of daily living (ADLs) for a resident with multiple medical diagnoses, including dementia, cognitive communication disorder, muscle weakness, and diabetes mellitus. The resident's Minimum Data Set (MDS) indicated she needed partial to moderate assistance with lower body dressing, footwear, bathing, toileting, and oral hygiene, and supervision or touch assistance with upper body dressing, personal hygiene, bed mobility, and walking. The Functional Abilities Care Area Assessment (CAA) also indicated a need for staff assistance with ADLs and self-care. However, the care plan did not specify the resident's current level of functioning or the required level of assistance for bathing, transfers, dressing, oral hygiene, meals, and bed mobility. Observations showed the resident was able to walk with a walker and prepare for meals independently, and she reported no concerns about her care. Interviews with staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that care plans should include detailed information about each resident's level of functioning and assistance needs. The facility's policy required comprehensive assessments and individualized interventions, with care plans reviewed and updated as needed, but this was not reflected in the resident's care plan documentation.
Failure to Follow Physician's Orders for Weight Monitoring in CHF Patient
Penalty
Summary
The facility failed to follow a physician's order for daily and weekly weights for a resident diagnosed with congestive heart failure (CHF), among other conditions. The resident's electronic medical record (EMR) included orders for daily weights for three consecutive days and weekly weights thereafter, which were not documented as completed on the specified dates. The July Medication Administration Record (MAR), Treatment Administration Record (TAR), and Weights/Vital Signs tab lacked evidence of daily weights for three days and weekly weights for two separate weeks. Interviews with staff confirmed that the process for obtaining and documenting weights involved communication between CNAs and nurses, with the charge nurse responsible for ensuring orders were followed and weights were recorded in the EMR. The resident had a history of CHF, overactive bladder, pain, dementia, cellulitis, lack of coordination, communication deficit, need for assistance with personal care, a healing fracture, and Parkinson's disease. The care plan required nursing staff to administer medications as ordered and monitor for side effects, with specific mention of monitoring for adverse effects of medication every shift. Despite these directives, the required weights were not obtained or documented as ordered, resulting in a failure to provide care in accordance with the physician's orders and the facility's policy.
Failure to Provide Ordered Pressure-Reducing Device for At-Risk Resident
Penalty
Summary
A deficiency occurred when a resident, identified as being at risk for pressure ulcers due to impaired mobility and incontinence, did not have a physician-ordered pressure-reducing cushion in place on their wheelchair. The resident's medical record documented diagnoses including difficulty walking, dementia, lack of coordination, muscle weakness, and a need for assistance with personal care. The care plan and assessments indicated the resident was at risk for pressure-related injuries and required monitoring and assistance with turning and repositioning. Despite a physician order for a cushion to be used in the wheelchair, multiple observations over several days found the resident's wheelchair lacked the required cushion, and no cushion was present in the room. Interviews with staff revealed inconsistent understanding and implementation of responsibilities regarding pressure-reducing devices. Certified Nurse Aides and Licensed Nurses stated that ensuring pressure-reducing devices were in place was a shared responsibility, and that such devices should be listed on the resident's care plan or Kardex. However, there was uncertainty among staff about which residents required these devices, and the ordered cushion was not in use as required by the resident's care plan and physician order. The facility's policy required pressure-reducing devices for individuals restricted to a chair, but this was not followed for the resident in question.
Failure to Store Nebulizer Mask in a Sanitary Manner
Penalty
Summary
A deficiency was identified when a resident's nebulizer mask was repeatedly observed stored in an unsanitary manner, specifically left on the bedside table rather than in a clean, designated container. The resident had multiple medical conditions, including hypertension, peripheral vascular disease, bilateral below-knee amputations, a colostomy, muscle weakness, and required significant assistance with activities of daily living. The resident was prescribed Ipratropium-Albuterol nebulizer treatments three times daily for wheezing. Despite staff interviews indicating that nebulizer masks should be rinsed, air dried, and stored in a dated plastic bag, direct observations on multiple occasions showed the mask left out on the bedside table. The resident's care plan did not include instructions for nebulizer use or mask storage, and the facility was unable to provide a policy regarding proper storage of nebulizer masks. These actions and omissions led to the failure to ensure safe and sanitary respiratory care for the resident.
Incomplete and Undated Laboratory Records
Penalty
Summary
The facility failed to keep complete, dated laboratory records in the resident's record. This deficiency was identified through review of documentation, which revealed that laboratory records were either incomplete or missing required dates. The lack of proper documentation was directly observed in the resident's medical record.
Failure to Coordinate Hospice and Facility Care Plans
Penalty
Summary
The facility failed to ensure a coordinated plan of care between the facility and hospice services for a resident who was admitted to hospice. The resident had multiple diagnoses, including fibromyalgia, hypertension, peripheral vascular disease, major depressive disorder, diabetes mellitus, muscle weakness, and senile degeneration of the brain, and required significant assistance with activities of daily living. The resident's care plan documented admission to hospice and outlined comfort measures, maintenance of dignity, and the provision of supplies by hospice. However, review of records and staff interviews revealed that information regarding hospice services, such as supplies provided and the schedule of hospice staff, was not consistently included in the facility's care plan. Instead, this information was maintained separately in a hospice binder at the nurse's station, and staff relied on verbal communication and the binder for updates. Certified Nursing Aides and Licensed Nurses reported that they did not believe hospice information was integrated into the facility's care plan, and the Administrator confirmed that while communication with hospice was good, the care plans between the facility and hospice should match. The facility's policy required individualized, interdisciplinary plans to address residents' needs, but the lack of a unified, coordinated care plan placed the resident at risk for inappropriate end-of-life care. The deficiency was identified through observation, record review, and staff interviews, which demonstrated a failure to develop and maintain a coordinated plan of care as required.
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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 Leawood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tallgrass Creek, Inc | 1.3 mi | ★★★★★ | 15 | 0 |
| Ignite Medical Resort Overland Park Llc | 1.5 mi | ★★★★★ | 1 | 0 |
| Village Shalom Inc | 2.6 mi | ★★★★★ | 0 | 0 |
| Brookdale Overland Park | 3 mi | ★★★★★ | 11 | 0 |
| Colonial Village | 4.7 mi | ★★★★★ | 0 | 0 |
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