The Healthcare Resort of Leawood - Iron Horse HLTH

In the surveyor’s words

From the most serious findings on record at The Healthcare Resort of Leawood - Iron Horse HLTH, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Feb 11, 2026

  The facility identified a census of 59 residents with a census of 28 residents on the East unit. Based on observation, record review, and interviews, the facility failed to prevent two Certified Nurse Aides (CNAs) from bringing weapons into the facility and further failed to prevent gun violence between the two CNAs on the East unit. On 02/10/26 at approximately 03:28 AM, CNA M went down the Northeast (NE) corridor and unlocked the door that led to an exit outside. He then walked back down the hallway towards the nurses' station, pulled a gun out of his jacket, and fired multiple shots into the dining room where CNA N was located. […]

• Immediate jeopardy, patternF689Jul 20, 2021

  The facility reported a census of 52 residents. The sample included three residents reviewed for elopement (when a cognitive impaired resident with little or poor safety awareness exits the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received adequate supervision with audible door and Wander Guard alarms to prevent elopement. R1, who was on the West unit, exited the facility without staff knowledge and supervision on 07/14/21 between approximately 04:30 PM and 04:40 PM. R1 exited through the fire exit door on the South side of the building. R1 pushed on the door for approximately 15 seconds and then exited the facility. […]

• Actual harm, isolatedF689Jun 23, 2022

  The facility identified a census of 53 residents. The sample included three residents, with three residents reviewed for accidents. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free of accidents when facility staff failed to use a gait belt (belt used to help transfer a person from one place to another) during a transfer in the bathroom, which resulted in a fall. This deficient practice resulted in a fracture of R1's right femur (thigh bone). […]

• No harm, potential for more than minimal, widespreadF730Aug 6, 2025

  The facility had a census of 64 residents. The sample included 14 residents. Five Certified Nurse Aides (CNA) were reviewed for yearly performance evaluations and in-service training. Based on record review and interview, the facility failed to ensure one of the five reviewed CNA staff had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - Review of the facility's performance evaluation and in-service records revealed the following: CNA N, hired on 10/11/23, had no yearly performance evaluations provided upon request. On 08/06/25 at 12:15 PM, Administrative Nurse D stated the facility did not have the required yearly performance evaluations for CNA N. […]

• No harm, potential for more than minimal, widespreadF812Aug 6, 2025

  The facility identified a census of 64 residents. The facility had one kitchen and two kitchenettes. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to a dirty top of the convection oven with a water bucket on the floor with dripping water, no hairnets worn, and improper food storage. This deficient practice placed the residents at risk for food-borne illness.Findings included:- During the initial tour on 08/04/25 at 07:14 AM, observation revealed the following:Dietary staff CC and dietary staff DD were not wearing hairnets in the kitchen.In the walk-in refrigerator, there was a steam table pan with hot dogs, hamburgers, a bowl with cut-up watermelon, a bowl of lettuce, and a steam table pan with corn salad that were not… […]