Cycle 1
Health 2024-04-30 · Fire 2024-04-30
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Derby, KS
Derby Health & Rehabilitation, LLC
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
731 Klein Circle, Derby, KS
(316) 719-2400
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
74
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-02-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
3.07
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
4.94
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.87
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
4.13
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
5.42
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
597
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.79
Composite VBP score used to determine payment impact.
Payment multiplier
1.0206
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.41
Baseline 16.68% · Performance 17.07% · Measure score 9.41 · Achievement 9.41 · Improvement 0
Healthcare-associated infections
8.98
Baseline 4.38% · Performance 5.15% · Measure score 8.98 · Achievement 8.98 · Improvement 0
Total nurse turnover
1.51
Baseline 77.88% · Performance 67.24% · Measure score 1.51 · Achievement 0 · Improvement 1.51
Adjusted total nurse staffing
6.82
Baseline 4.94 hours · Performance 5.02 hours · Measure score 6.82 · Achievement 6.82 · Improvement 0.40
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.08% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 531 · Observed rate 8.66% · Lower 95% interval 8.18% |
| Discharge to community | 65.38% |
50.57%
14.8 pts better
|
Better than the National Rate · Eligible stays 518 · Observed rate 65.06% · Lower 95% interval 61.36% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.06% |
95.27%
3.8 pts better
|
Numerator 316 · Denominator 319 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 319 |
| Discharge self-care score | 60.15% |
53.69%
6.5 pts better
|
Numerator 163 · Denominator 271 |
| Discharge mobility score | 57.93% |
50.94%
7 pts better
|
Numerator 157 · Denominator 271 |
| Pressure ulcers or injuries, new or worsened | 1.88% |
2.29%
0.4 pts better
|
Numerator 6 · Denominator 319 · Adjusted rate 2.35% |
| Healthcare-associated infections requiring hospitalization | 5.15% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 313 · Observed rate 3.19% · Lower 95% interval 3.09% |
| Staff COVID-19 vaccination coverage | 0.64% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 157 |
| Staff flu vaccination coverage | 78.02% |
42%
36 pts better
|
Numerator 252 · Denominator 323 |
| Discharge function score | 66.79% |
56.45%
10.3 pts better
|
Numerator 181 · Denominator 271 |
| Transfer of health information to provider | 98.28% |
95.95%
2.3 pts better
|
Numerator 57 · Denominator 58 |
| Transfer of health information to patient | 97.84% |
96.28%
1.6 pts better
|
Numerator 226 · Denominator 231 |
| Resident COVID-19 vaccinations up to date | 21.84% |
25.2%
3.4 pts worse
|
Numerator 38 · Denominator 174 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
2.2
1.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
91.8%
5.8 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.2% · Q3 97.5% · Q4 97.7% · 4Q avg 97.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.9% |
95.5%
2.4 pts better
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.1% |
4.4%
2.7 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 9.5% · Q3 7.5% · Q4 2.3% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.9% |
5.6%
1.7 pts better
|
11.4%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.7% · Q3 2.9% · Q4 0.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.0%
0.9 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 3.4% · Q3 3.8% · Q4 6.5% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.1% |
23.2%
2.1 pts better
|
19.6%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 16.7% · Q3 22.2% · Q4 19.4% · 4Q avg 21.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.9% |
19.8%
5.9 pts better
|
16.7%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 13.0% · Q3 17.4% · Q4 10.3% · 4Q avg 13.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 30.8% |
18.4%
12.4 pts worse
|
16.3%
14.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.8% |
18.8%
1 pts worse
|
14.9%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 20.7% · Q3 11.1% · Q4 9.7% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.8%
1.1 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
3.1%
0.1 pts better
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 7.7% · Q4 2.3% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.7% |
23.2%
10.5 pts worse
|
19.8%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 34.8% · Q3 49.1% · Q4 27.5% · 4Q avg 33.7% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
4.6%
1.1 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.8% · Q3 8.7% · Q4 7.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.4% |
75.6%
14.8 pts better
|
81.7%
8.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.7% · Q2 89.9% · Q3 91.7% · Q4 89.6% · 4Q avg 90.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
11.7%
2.8 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 8.4% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.2%
0.6 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 1.2% · Q4 1.8% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.2% |
73.5%
13.7 pts better
|
79.7%
7.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
23.0%
1.4 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 22.2% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-08 · Fire 2022-11-08
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-05-12 · Fire 2021-05-12
0 health deficiencies
No concentrated health issue counts in this cycle.
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-30
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-04-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-04-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-04-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-04-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-04-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-21
F · Potential for more than minimal harm
2024-04-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-21
F · Potential for more than minimal harm
2022-11-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-01-05
F · Potential for more than minimal harm
2022-11-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-05
F · Potential for more than minimal harm
2022-11-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-05
E · Potential for more than minimal harm
2022-11-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-05
E · Potential for more than minimal harm
2022-11-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-05
F · Potential for more than minimal harm
2021-05-12
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-12
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-12
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-06-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-05
E · Potential for more than minimal harm
2024-04-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-04-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-04-30
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-04-30
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-04-30
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-04-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-04-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-05
D · Potential for more than minimal harm
2022-11-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-11-08
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-11-18
D · Potential for more than minimal harm
2022-11-08
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-11-18
C · Minimal harm
2022-11-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-11-18
Penalties and ownership
What sits behind the stars
Ownership
Axiom Healthcare Alliance, LLC
5% Or Greater Direct Ownership Interest · Organization
Lakin, Gregory
5% Or Greater Indirect Ownership Interest · Individual
Wichita Wellness Inc
5% Or Greater Indirect Ownership Interest · Organization
Axiom Consulting LLC
5% Or Greater Indirect Ownership Interest · Organization
Hermes, Frederick
5% Or Greater Indirect Ownership Interest · Individual
Lillie, Matthew
5% Or Greater Indirect Ownership Interest · Individual
Matt Lillie Investments, Inc
5% Or Greater Indirect Ownership Interest · Organization
Evans, Roger
5% Or Greater Indirect Ownership Interest · Individual
Roger Evans Revocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Dennis L. Ross Pod To Trustee Of Dennis L. Ross Living Trust U/A 4/4/1
5% Or Greater Indirect Ownership Interest · Organization
Ross, Ann
5% Or Greater Indirect Ownership Interest · Individual
Ross, Dennis
5% Or Greater Indirect Ownership Interest · Individual
Axiom Healthcare Services LLC
Operational/Managerial Control · Organization
Becnel, Chance
Corporate Officer · Individual
Hermes, Frederick
W-2 Managing Employee · Individual
Kruse, Brenda
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Westview Of Derby Rehabilitation & Health Care Cen
Derby, KS
2-star overall rating with 1-star inspections with $74,296 in total fines with 19 recent health deficiencies with 26 fire-safety deficiencies in the latest cycle
#2
Villa Maria
Mulvane, KS
5-star overall rating with 5-star inspections with $22,081 in total fines with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Advena Living At Fountainview
Rose Hill, KS
3-star overall rating with 3-star inspections with $38,759 in total fines with 6 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
Jump out