The Healthcare Resort of Leawood - Iron Horse Hlth

Inspectors wroteThe 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. CNA N returned an unknown number of rounds down the East Hall, where nine residents resided, with a bullet grazing the wall next to Resident (R) 2's room and a bullet, possibly the same one, hitting the doorframe of R1's room. [...]

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area and out of reach of eight cognitively impaired, independently mobile residents. The facility additionally failed to ensure Resident (R) 29's fall interventions were implemented. This placed the affected residents at risk for preventable accidents. Findings Included: - On 08/04/25 at 07:10 AM, an initial walkthrough of the facility was completed. An inspection of the Hallbrook unit revealed an unsecured soiled utility closet. An inspection of the closet revealed a bottle of solution under the sink. The bottle contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed. [...]

Inspectors wroteThe facility reported a census of 64 residents. The facility identified two medication carts and two treatment carts. Based on observations, record review, and interviews, the facility failed to secure its two treatment carts. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included-- On 08/04/25 at 07:00 AM, an initial walkthrough of the facility was completed. An inspection of the Hallbrook unit revealed an unlocked treatment cart in the back nurses' station. An inspection of the cart revealed medical ointments and wound cleansers. An inspection of the Bridgewood unit revealed an unlocked treatment cart in the hallway. An inspection of the cart revealed medical ointments and wound cleansers. On 08/05/25 at 01:23 PM, an inspection of the medication storage room on the Hallbrook unit was completed. [...]

Inspectors wroteThe facility identified a census of 64 residents. The facility identified 14 residents on Enhanced Barrier Precautions (EBP- infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to store linens in a sanitary manner, the facility further failed to ensure dirty linens were not placed on the floor, and the facility further failed to ensure a barrier was placed on the countertop, before Accu-check (blood glucose monitoring test) monitor was laid on counter. The facility additionally failed to store Resident (R) 3 and R42's respiratory equipment in a sanitary manner. These deficient practices placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents, with five residents reviewed for immunization status. Based on record reviews and interviews, the facility failed to obtain consent or declinations for the Pneumococcal Conjugate Vaccine (PCV20- vaccination for bacterial infections), pneumococcal (type of bacterial infection) vaccination for Resident (R) 12 and R75. This placed the residents at increased risk for complications related to pneumonia.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents, with two reviewed for reasonable accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 51 had a way to communicate her needs due to her call light being left out of reach. This deficient practice placed the R51 at risk for preventable accidents and injuries. Findings Included:- The Medical Diagnosis section within R51's Electronic Medical Records (EMR) included diagnoses of muscle weakness, overactive bladder, need for assistance with personal care, history of falling, and cognitive communication disorder (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). [...]

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents, with two residents reviewed for hospitalization. Based on observation, record review, and interviews, the facility failed to provide a final summary of the resident's status at discharge for Resident (R) 6. This deficient practice placed R6 at risk of delayed care or uncommunicated care needs.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents, with 16 reviewed for care planning. Based on observation, record review, and interviews, the facility failed to identify the level of care assistance needed for activities of daily living (ADL) on Resident (R) 54's care plan. This deficient practice placed R54 at risk for ineffective treatment and preventable accidents. Findings Included: [...]

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents, with one resident reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to ensure the physician's order was followed for a daily weight for R5 to monitor for congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid). This deficient practice placed R5 at risk of delayed treatment and untreated illness.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents, with five residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing devices were in place for Resident (R) 12, who was at risk for the development of pressure ulcers. This deficient practice placed R12 at risk for complications related to skin breakdown.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 15 residents, with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 3's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask was stored in a sanitary manner. This placed R3 at an increased risk for respiratory infection and complications.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 16 residents. Based on observation, record review, and interviews, the facility failed to ensure physician-ordered laboratory test results for Resident (R) 42, R5, and R75 were included in the clinical record. This deficient practice could result in unnecessary tests and delayed treatment.

Inspectors wroteThe facility identified a census of 64 residents. The sample included 15 residents, with two residents reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 13. This placed the resident at risk for inappropriate end-of-life care.

Inspectors wroteThe facility identified a census of 63 residents. The facility had one main kitchen and two kitchenette serving areas. Based on observation, record review and interview, the facility failed to ensure that dietary staff appropriately dated, labeled, and stored opened foods. This deficient practice had the potential for food borne illnesses for residents.

Inspectors wroteThe facility reported a census of 63. Based on observations, record review, and interviews, the facility failed to adequately address and resolve recurring issues reported by the Resident Council. This deficient practice placed the residents at risk for decreased psychosocial wellbeing and impaired quality of life. Findings Included- - A review of the facility's Resident Council Minutes from 11/2022 through 11/2023 indicated the council had recurring concerns with staff not verifying meal tickets, offering choices, availability of snacks and fruits and vegetables, not taking orders before meal service, and posting the daily menus. Further recurring issues were call light response times. The Resident Council Minutes form instructed any old business that was unresolved be moved to new business. [...]

Inspectors wroteThe facility identified a census of 63 residents. The sample included 17 residents with two reviewed for grievances. Based on observation, record review, and interviews, the facility failed to adequately resolve Resident (R)26's grievances related to her ongoing dietary concerns. This deficient practice placed R26 at risk for decreased psychosocial wellbeing. Findings Included: - The Medical Diagnosis section within R26s Electronic Medical Records (EMR) included diagnoses of quadriplegia (inability to move the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), major depressive disorder (major mood disorder), muscle weakness, abnormal posture, and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). [...]

Inspectors wroteThe facility had a census of 63 residents. The sample included 17 residents with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure rooms containing hazardous materials out of reach of 17 cognitively impaired /independently mobile residents. This deficient practice placed the affected residents at risk for preventable injuries and accidents.

Inspectors wroteThe facility identified a census of 63 residents. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care, disinfecting shared equipment, and storage of oxygen tubing when not in use. This deficient practice placed the residents at risk for complications related to infectious diseases.

Inspectors wroteThe facility identified a census of 63 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure that resident's rights and dignity were respected by staff when Resident (R) 16 and R1, both dependent residents, sat at the dining table as staff stood in between these residents to assist them with eating. This placed the residents at risk for decreased self-esteem and impaired dignity.

Inspectors wroteThe facility identified a census of 63 residents. The sample included 17 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide consistent bathing opportunities for Resident (R)26, R4, and R15. This deficient practice placed both residents at risk for infections, skin breakdown, and impaired dignity. Findings Included: - The Medical Diagnosis section within R26's Electronic Medical Records (EMR) included diagnoses of quadriplegia (inability to move the arms, legs and trunk of the body below the level of an associated injury to the spinal cord)., major depressive disorder (major mood disorder), muscle weakness, abnormal posture, and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). [...]

Inspectors wroteThe facility identified a census of 63 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to ensure the standard of care was provided during catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care and failed to prevent the catheter drainage bag from touching the floor for Resident (R)15 who had a history of frequent urinary tract infection (UTI-an infection in any part of the urinary system). This deficient practice placed R15 at risk of catheter related complications and further UTIs.

Inspectors wroteThe facility identified a census of 63 residents. The sample included 17 residents with five residents sampled for nutrition. Based on observations, record review, and interviews, the facility failed to ensure ordered dietary supplements, to promote increased calorie intake, were monitored for effectiveness and failed to ensure weekly weights were obtained as ordered for Resident (R) 59. This deficient practice placed R59 at risk for continued weight loss and possible malnutrition.

Inspectors wroteThe facility identified a census of 63 residents. The sample included 17 residents with five residents sampled for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported that Resident (R) 18's pulse was not being monitored as physician ordered prior to administration of carvedilol (beta blocker-medication used to treat high blood pressure and heart failure). This placed R18 at risk of unnecessary medication administration and possible adverse side effects.

Inspectors wroteThe facility identified a census of 63 residents. The sample included 17 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure dosing instructions for Voltaren (topical pain reliever medication) gel for Resident (R) 15. The facility also failed to follow physician ordered parameters for R18's antihypertensive beta-blocker (class of medication used to treat high blood pressure). This deficient practice had the risk for unnecessary medication use and physical complications for the affected residents.

Inspectors wroteThe facility identified a census of 63 residents. The sample included 17 residents with three reviewed for dietary preferences. Based on observation, record review, and interviews, the facility failed to follow Resident (R)26's cultural dietary preferences. This deficient practice placed R26 at risk for decreased psychosocial wellbeing and weight loss. Findings Included: - The Medical Diagnosis section within R26s Electronic Medical Records (EMR) included diagnoses of quadriplegia (inability to move the arms, legs and trunk of the body below the level of an associated injury to the spinal cord), major depressive disorder (major mood disorder), muscle weakness, abnormal posture, and multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord). [...]

Inspectors wroteThe facility had a census of 53 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to handle linens appropriately in order to reduce transmission of infectious diseases when the facility failed to cover clean laundry while delivering to resident rooms, and wear protective equipment (gown) when sorting soiled linens. The facility further failed to ensure appropriate use of cleaning products and techniques for disinfection of clostridioides difficile (C-Diff- a bacterium that causes diarrhea and inflammation of the colon which can be life-threatening) rooms which placed the residents and staff at increased risk for infection.

Inspectors wroteThe facility had a census of 53 residents. The sample included 14 residents. Based on record review and interview, the facility failed to develop a baseline care plan for one sampled resident, Resident (R) 50, upon admission. This placed the resident at risk for inappropriate care.

Inspectors wroteThe facility had a census of 53 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 39, who had a fluid restriction related to his dialysis (the process of removing excess water, solutes and toxins from the blood in people whose kidneys can no longer perform). This placed R39 at risk of complications related to fluid overload or dehydration.

Inspectors wroteThe facility had a census of 53 residents. The sample included 14 residents, with three reviewed for skin condition not pressure related. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent skin tears for one sampled resident, Resident (R) 157, who received two skin tears during cares. This placed R157 at risk for further injury.

Inspectors wroteThe facility had a census of 53 residents. The sample included 14 residents with one resident reviewed for discharge. Based on observation, record review, and interview, the facility failed to complete a discharge summary for Resident (R) 49 that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) summary of the resident's stay in the facility. This placed R49 at risk for miscommunication or interruptions in the continuum of care after discharge.

Inspectors wroteThe facility had a census of 53 residents. The sample included 14 residents, with one reviewed for communication. Based on observation, record review, and interview, the facility failed to use alternative communication methods for one sampled resident, Resident (R) 17, who had a diagnosis of cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition). This placed the resident at risk for ineffective communication and frustration.

Inspectors wroteThe facility had a census of 53 residents. The sample included 14 residents, with three reviewed for skin condition not pressure related. Based on observation, record review, and interview, the facility failed to implement interventions to prevent skin tears for one sampled resident, Resident (R) 157, who received two skin tears during cares. This placed R157 at risk for further injury.

Inspectors wroteThe facility had a census of 53 residents. The sample included 14 residents with one reviewed for dialysis (the process of removing excess water, solutes and toxins from the blood in people whose kidneys can no longer perform). Based on observation, record review, and interview, the facility failed to implement a physician ordered fluid restriction for Resident (R) 39, who had dialysis treatment. This placed R39 at risk of complications related to fluid overload or dehydration.

Inspectors wroteThe facility had a census of 53 residents. The sample included 14 residents. Based on record review and interview, the facility failed to ensure medication was administered per physician orders for Resident (R) 158. This deficient practice placed the resident at risk for decreased well-being and ineffective medication regimen.