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
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing
LPN hours / resident day
1.26
Licensed practical nurse staffing
Aide hours / resident day
3.07
Nurse aide staffing
Weekend hours
4.13
Weekend nurse staffing
RN turnover
53%
Annual RN turnover
Total nurse turnover
59%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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