The Healthcare Resort of Leawood - Iron Horse HLTH
5401 W 143rd Street, Leawood, KS 66224 · Johnson County · 70 certified beds · avg 62 residents/day · certified since Dec 7, 2016
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
2/5
Health inspection rating (on-site)
1
Serious findings on record
$12,418
Fines, last 3 years
3.98
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, facility-wide · Feb 11, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (L): A life-threatening or extremely dangerous situation existed throughout the facility. The single most serious citation CMS can issue.
Corrected: Feb 10, 2026 (Past Non-Compliance)
All citations in the current public record (36)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 11, 2026 | ▲ L · Immediate jeopardy, facility-wide | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 6, 2025 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Aug 6, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 6, 2025 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 6, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 6, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 6, 2025 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not keep complete, dated laboratory records in residents' files. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Nov 16, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 16, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Nov 16, 2023 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Mar 7, 2022 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 7, 2022 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Mar 7, 2022 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 7, 2022 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Mar 7, 2022 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. |
| Mar 7, 2022 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Mar 7, 2022 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Mar 7, 2022 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Mar 7, 2022 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (12 → 14).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 9 | 0 | F |
| 2023 | 12 | 0 | F |
| 2025 | 14 | 0 | F |
| 2026 | 1 | 1 | L ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $12,418.
| Date | Type | Amount / length |
|---|---|---|
| Feb 11, 2026 | Fine | $12,418 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Kansas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.98 | 4.58 | 3.95 | bottom 33% in Kansas; top 40% in the U.S. |
| Registered Nurse hours | 0.74 | 0.81 | 0.69 | top 47% in Kansas; top 32% in the U.S. |
| Weekend total nurse staffing | 3.70 | 4.05 | 3.50 | bottom 39% in Kansas; top 33% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.40 | 0.49 | 0.48 | bottom 42% in Kansas; top 47% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 48.1 | 45.8 | — |
| RN turnover (%) | 0.0 | 42.0 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.05, RN 0.76, weekend 3.76. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Gateway Healthcare LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 01/22/2015 |
| Bohrer, Tracy | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/07/2020 |
| Bohrer, Tracy | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/07/2020 |
| Bohrer, Tracy | Individual | ADP of the SNF | NOT APPLICABLE | 05/06/2025 |
| Burnam, Soon | Individual | Managing Control - Governing Body | NOT APPLICABLE | 02/04/2015 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 02/04/2015 |
| Geha, Christopher | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/10/2020 |
| Geha, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 01/10/2020 |
| Jorgensen, David | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 06/24/2025 |
| Keetch, Chad | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 06/24/2025 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 06/24/2025 |
| The Ensign Group INC | Organization | ADP of the SNF | NOT APPLICABLE | 01/22/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How often do you evaluate your nurse aides and what ongoing training do they receive?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Tallgrass Creek, INC | 1.3 mi | Overland Park, KS | ★★★★★ | 5/5 | |
| Ignite Medical Resort Overland Park LLC | 1.5 mi | Overland Park, KS | ★★☆☆☆ | 2/5 | |
| Village Shalom INC | 2.6 mi | Overland Park, KS | ★★★★☆ | 2/5 | |
| Brookdale Overland Park | 3.0 mi | Overland Park, KS | ★★★★☆ | 4/5 | |
| Advanced Health Care of Overland Park | 4.7 mi | Overland Park, KS | ★★★★★ | 3/5 | |
| Colonial Village | 4.7 mi | Overland Park, KS | ★★☆☆☆ | 2/5 | |
| Stratford Commons Rehab & Health Care Center | 4.8 mi | Overland Park, KS | ★★★☆☆ | 3/5 | |
| Bridgewood Health Care Center | 5.0 mi | Kansas City, MO | ★☆☆☆☆ | 1/5 | abuseSFF |
| Overland Park Post Acute | 5.0 mi | Overland Park, KS | ★☆☆☆☆ | 1/5 | |
| Swan Health at Overland Park | 5.1 mi | Overland Park, KS | ★☆☆☆☆ | 1/5 | |
| Ignite Medical Resort Carondelet LLC | 5.2 mi | Kansas City, MO | ★☆☆☆☆ | 2/5 | |
| Nottingham Health and Rehabilitation | 5.4 mi | Olathe, KS | ★★★★★ | 5/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 175558.