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Health Inspection Summary

Derby Health & Rehabilitation, LLC

731 Klein Circle

Derby, KS 67037

(316) 719-2400

Deficiency Category	Inspection Date: 4/30/24 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 11/8/22 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 5/12/21 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	1	0	0
Quality of Life and Care Deficiencies	2	2	0
Infection Control Deficiencies	0	0	0
Resident Assessment and Care Planning Deficiencies	0	0	0
Nursing and Physician Services Deficiencies	0	1	0
Resident Rights Deficiencies	1	0	0
Nutrition and Dietary Deficiencies	1	0	0
Pharmacy Service Deficiencies	2	1	0
Environmental Deficiencies	0	0	0
Administration Deficiencies	0	0	0

Detailed result for inspection on 4/30/24

Date of last standard health inspection:	4/30/24Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	4/30/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	7
Average number of Health Deficiencies in Kansas:	10.4
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from the wrongful use of the resident's belongings or money.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident’s drug regimen must be free from unnecessary drugs.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 11/8/22

Date of last standard health inspection:	11/8/22Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	7/12/23Read the full report (PDF)
Total number of Health Deficiencies for this nursing home:	4
Average number of Health Deficiencies in Kansas:	8.8
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	11/8/22	11/18/22	2 - Minimal harm or potential for actual harm	Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	11/8/22	11/18/22	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Post nurse staffing information every day.	11/8/22	11/18/22	1 - Potential for minimal harm	Many

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure 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.	11/8/22	11/18/22	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 5/12/21

Date of last standard health inspection:	5/12/21Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	No complaint inspections
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	0
Average number of Health Deficiencies in Kansas:	6.6
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
No Quality of Life and Care Deficiencies were found during this inspection period.

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Protect each resident from the wrongful use of the resident's belongings or money.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Some
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Some
Ensure each resident’s drug regimen must be free from unnecessary drugs.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	4/30/24	6/5/24	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years.

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