Map showing the location of THE HEALTHCARE RESORT OF LEAWOOD - IRON HORSE HLTH in LEAWOOD, Kansas
5401 W 143RD STREET, LEAWOOD, KS, 66224

Overall Score

CMS Five-Star Quality Rating
3/5AverageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • KansasAbove only 40% of peers294 rated homes · average 3.0★
  • Johnson CountyAbove only 44% of peers35 rated homes · average 2.7★
  • United StatesAbove only 41% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs KS avg
  • StaffingCan add or remove a star3★−0.4 vs KS avg
  • Quality measuresCan add or remove a star5★+1.9 vs KS avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersKS avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 24% of peersKS avg3.4★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 81% of peersKS avg3.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.95hrsAbove 50% of peersKS avg4.07Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.67hrsAbove 52% of peersKS avg0.71Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better55%Above only 34% of peersKS avg50%RN turnover39%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above 50% of peersKS avg$21,017Fines · denials0 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
35citations
3inspection dates
0actual harm (G–I)
0immediate jeopardy (J–L)
Aug 6, 2025most recent

Citations by monthMar 2022 – Aug 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Aug 6, 202514 citationsCycle 1worst F · no actual harm
  1. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Sep 15, 2025
  2. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Sep 15, 2025
  3. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 15, 2025
  4. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Sep 15, 2025
  5. F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsD · isolatedCorrected Sep 15, 2025
  6. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Sep 15, 2025
  7. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Sep 15, 2025
  8. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Sep 15, 2025
  9. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Sep 15, 2025
  10. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesF · widespreadCorrected Sep 15, 2025
  11. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceE · patternCorrected Sep 15, 2025
  12. F775Keep complete, dated laboratory records in the resident's record.AdministrationD · isolatedCorrected Sep 15, 2025
  13. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Sep 15, 2025
  14. F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationD · isolatedCorrected Sep 15, 2025
Nov 16, 202312 citationsCycle 2worst F · no actual harm
  1. F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Dec 15, 2023
  2. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Dec 15, 2023
  3. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Dec 15, 2023
  4. F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsE · patternCorrected Dec 15, 2023
  5. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Dec 15, 2023
  6. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Dec 15, 2023
  7. F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Dec 15, 2023
  8. F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Nutrition and DietaryD · isolatedCorrected Dec 15, 2023
  9. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Dec 15, 2023
  10. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Dec 15, 2023
  11. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Dec 15, 2023
  12. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Dec 15, 2023
Mar 7, 20229 citationsCycle 3worst F · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Apr 8, 2022
  2. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Apr 8, 2022
  3. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Apr 8, 2022
  4. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Apr 8, 2022
  5. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Apr 8, 2022
  6. F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Resident Assessment and Care PlanningD · isolatedCorrected Apr 8, 2022
  7. F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Apr 8, 2022
  8. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Apr 8, 2022
  9. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Apr 8, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.95hrsAbove 50% of peers−0.12 vs KS avg
  • Registered nursesRN hours only0.67hrsAbove 52% of peers−0.04 vs KS avg
  • Licensed practical nursesLPN hours0.67hrs
  • Nurse aidesCNA hours2.61hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.58hrs
  • Kansas average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better55%Above only 34% of peersKS avg 50%
  • RN turnoverRegistered nurses only39%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy70 certified beds · ~65 residents a day93%Above 85% of peersKS avg 82%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $0In fines
  • 0Fines
  • 0Payment denials
  • $21,017KS avg in fines
Above 50% of peersFewer fines than 50% of rated homes in Kansas

Actions on record

No fines or payment denialsNothing on record in the current reporting window. Kansas facilities average 1.3 penalties.

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
The Ensign Group324 facilities in the chain3.2★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Gateway Healthcare LLC
Operational or managerial control
  • Tracy Bohrer
Corporate directors
  • Spencer Burton
Corporate officers
  • Soon Burnam
  • Craig Fitch
  • Corwin Lewis
Managing employees
  • Tracy Bohrer

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 175558 · 5401 W 143RD STREET, LEAWOOD, KS, 66224.
  • Percentiles compare this facility with every rated nursing home in Kansas and Johnson County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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