Federal inspection record · CMS data as of October 1, 2026
Derby Health & Rehabilitation, LLC
731 Klein Circle, Derby, KS · (316) 719-2400
- CMS high-performer trophy
- Certified beds
- 74
- Residents per day
- 71
- Ownership
- For-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- February 16, 2010
1
How this home got 5 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Kansas.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★no change (already 5)
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★5 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Kansas homes
Derby Health & Rehabilitation, LLC carries 16 inspection points. That is fewer than 97% of Kansas's 293 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Kansas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–27 pts
- 4★ 27–49 pts
- 3★ 49–71 pts
- 2★ 71–114.38 pts
- 1★ over 114.38 pts
Bars show every rated home in Kansas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
14 health citations on record since 2022. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care6E
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
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.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Pharmacy Service3D
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- D
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.
Resident Rights2D
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Nutrition and Dietary1E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Nursing and Physician Services1C
- C
Post nurse staffing information every day.
Inspection history
2026-03-11
2 health deficiencies · 7 fire-safety deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2024-04-30
8 health deficiencies · 5 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2022-11-08
4 health deficiencies · 9 fire-safety deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 41 min of nursing staff time a day, 35 min of it from a registered nurse.
This home
4 h 41 min
Kansas average
4 h 8 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 58% of nursing staff and 50% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.4 pts better | 1.3 | 1.7 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.5 pts better | 0.5 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine5.2 pts better | 98.1% | 92.9% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine5.1 pts better | 100.0% | 94.9% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury3 pts better | 1.2% | 4.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms5.2 pts better | 1.4% | 6.6% | 13.5% |
| Percentage of long-stay residents who lose too much weight1.7 pts better | 3.1% | 4.8% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.7 pts worse | 24.1% | 23.4% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication6.6 pts better | 11.1% | 17.7% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened3 pts better | 11.5% | 14.5% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased7.6 pts better | 9.8% | 17.4% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.8 pts better | 0.6% | 1.4% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.3 pts better | 2.5% | 2.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence1.7 pts better | 19.9% | 21.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.2 pts better | 4.2% | 4.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine17.4 pts better | 94.5% | 77.1% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit5.9 pts better | 5.5% | 11.4% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.5 pts better | 1.1% | 1.6% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine22.5 pts better | 97.9% | 75.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission6.2 pts worse | 28.5% | 22.3% | 23.4% |
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Who owns and runs it
16 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Axiom Healthcare Alliance, LLC | 5% Or Greater Direct Ownership Interest · Organization | 100% | 4 facilities |
| Lakin, Gregory | 5% Or Greater Indirect Ownership Interest · Individual | 11% | 5 facilities |
| Wichita Wellness Inc | 5% Or Greater Indirect Ownership Interest · Organization | 11% | 4 facilities |
| Axiom Consulting LLC | 5% Or Greater Indirect Ownership Interest · Organization | 9% | 4 facilities |
| Hermes, Frederick | 5% Or Greater Indirect Ownership Interest · Individual | 9% | 4 facilities |
| Lillie, Matthew | 5% Or Greater Indirect Ownership Interest · Individual | 8% | 4 facilities |
| Matt Lillie Investments, Inc | 5% Or Greater Indirect Ownership Interest · Organization | 8% | 4 facilities |
| Evans, Roger | 5% Or Greater Indirect Ownership Interest · Individual | 6% | 4 facilities |
| Roger Evans Revocable Trust | 5% Or Greater Indirect Ownership Interest · Organization | 6% | 4 facilities |
| Dennis L. Ross Pod To Trustee Of Dennis L. Ross Living Trust U/A 4/4/1 | 5% Or Greater Indirect Ownership Interest · Organization | 5% | 4 facilities |
| Ross, Ann | 5% Or Greater Indirect Ownership Interest · Individual | 5% | 4 facilities |
| Ross, Dennis | 5% Or Greater Indirect Ownership Interest · Individual | 5% | 4 facilities |
| Axiom Healthcare Services LLC | Operational/Managerial Control · Organization | 0% | 4 facilities |
| Becnel, Chance | Corporate Officer · Individual | 0% | 5 facilities |
| Hermes, Frederick | W-2 Managing Employee · Individual | 0% | 4 facilities |
| Kruse, Brenda | Corporate Officer · Individual | 0% | 5 facilities |
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Fire safety
21 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke10F
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- F
Install corridor and hallway doors that block smoke.
- F
Provide properly protected cooking facilities.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- E
Install corridor and hallway doors that block smoke.
- F
Provide properly protected cooking facilities.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Install corridor and hallway doors that block smoke.
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Gas, Vacuum, and Electrical Systems3F
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Ensure proper usage of power strips and extension cords.
- F
Ensure proper usage of power strips and extension cords.
Emergency Preparedness3F
- F
Address subsistence needs for staff and patients.
- F
List the names and contact information of those in the facility.
- F
Address patient/client population and determine types of services needed.
Services2F
- F
Have properly installed electrical wiring and gas equipment.
- E
Have properly installed electrical wiring and gas equipment.
Miscellaneous2F
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F
Have simulated fire drills held at unexpected times.
Egress1F
- F
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
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Other homes nearby
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Westview Of Derby Rehabilitation & Health Care Cen
Derby, KS · Tutera Senior Living & Health Care
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 12 min
- Fines
- $73,806
-
Villa Maria
Mulvane, KS
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 4 h 4 min
- Fines
- $22,081
-
Advena Living At Fountainview
Rose Hill, KS · Advena Living Communities
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 10 min
- Fines
- $30,566