Cycle 1
Health 2025-03-05 · Fire 2025-03-05
19 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
26 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Derby, KS
Westview Of Derby Rehabilitation & Health Care Cen
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
445 N Westview Dr, Derby, KS
(316) 788-3739
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
78
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Tutera Senior Living & Health Care
Operator or chain grouping
Approved since
1992-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
25 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
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
0.49
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.57
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.31
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.68
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,390
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.18
Baseline 70.59% · Performance 62.90% · Measure score 1.18 · Achievement 0 · Improvement 1.18
Adjusted total nurse staffing
2.20
Baseline 3.54 hours · Performance 3.70 hours · Measure score 2.20 · Achievement 2.20 · Improvement 0.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.72% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 4% · Lower 95% interval 6.55% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 69 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.8
1 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.1 · Expected 2.7 · 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 0.7 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.8%
8.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.6% |
95.5%
6.9 pts worse
|
95.5%
6.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.0% |
4.4%
1.6 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.3% · Q3 7.7% · Q4 9.4% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 29.5% |
5.6%
23.9 pts worse
|
11.4%
18.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 28.1% · Q3 27.9% · Q4 43.4% · 4Q avg 29.5% |
| Percentage of long-stay residents who lose too much weight | 10.3% |
5.0%
5.3 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 14.8% · Q3 14.0% · Q4 7.3% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.1% |
23.2%
6.1 pts better
|
19.6%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 20.0% · Q3 19.3% · Q4 19.6% · 4Q avg 17.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.6% |
19.8%
2.8 pts worse
|
16.7%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 27.5% · Q3 23.3% · Q4 17.8% · 4Q avg 22.6% · 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 | 18.5% |
18.4%
0.1 pts worse
|
16.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 22.7% · Q3 13.6% · Q4 17.9% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.1% |
18.8%
0.7 pts better
|
14.9%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.5% · Q3 10.5% · Q4 12.7% · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.1%
3.1 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.3% |
23.2%
3.9 pts better
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 19.2% · Q3 16.7% · Q4 19.7% · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.6%
2.7 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 3.7% · Q4 1.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.2% |
75.6%
10.6 pts better
|
81.7%
4.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 78.3% · 4Q avg 86.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.2%
2.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 54.2% |
73.5%
19.3 pts worse
|
79.7%
25.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 54.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-18 · Fire 2023-05-18
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
21 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2021-09-30 · Fire 2021-09-30
18 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
L · Immediate jeopardy
2025-03-05
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 2025-06-03
F · Potential for more than minimal harm
2025-03-05
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-15
F · Potential for more than minimal harm
2025-03-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K924 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that anesthesia apparatus are tested after any adjustment, modification or repair.
Corrected 2025-06-03
F · Potential for more than minimal harm
2025-03-05
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2025-06-03
F · Potential for more than minimal harm
2023-05-18
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
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 2023-08-01
F · Potential for more than minimal harm
2023-05-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-05-17
F · Potential for more than minimal harm
2023-05-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-08-01
F · Potential for more than minimal harm
2023-05-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-01
E · Potential for more than minimal harm
2023-05-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-01
F · Potential for more than minimal harm
2021-09-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-30
F · Potential for more than minimal harm
2021-09-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-12
F · Potential for more than minimal harm
2021-09-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-11-12
F · Potential for more than minimal harm
2021-09-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-11-12
F · Potential for more than minimal harm
2021-09-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-12
F · Potential for more than minimal harm
2021-09-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-11-12
E · Potential for more than minimal harm
2021-09-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-11-12
E · Potential for more than minimal harm
2021-09-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-11-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-09-16
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 2025-10-10
F · Potential for more than minimal harm
2025-03-05
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 2025-04-18
F · Potential for more than minimal harm
2025-03-05
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-05
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-05
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-05
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 2025-04-18
E · Potential for more than minimal harm
2025-03-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-05
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 2025-04-18
E · Potential for more than minimal harm
2025-03-05
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-18
E · Potential for more than minimal harm
2025-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
F571 · Resident Rights Deficiencies
Health
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-18
D · Potential for more than minimal harm
2025-03-05
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 2025-04-18
G · Actual harm
2025-01-08
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 2025-01-31
J · Immediate jeopardy
2024-05-16
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 2024-05-16
D · Potential for more than minimal harm
2024-04-17
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-05-03
E · Potential for more than minimal harm
2024-03-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-03
J · Immediate jeopardy
2024-01-10
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 2024-01-01
J · Immediate jeopardy
2023-09-26
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 2023-09-23
F · Potential for more than minimal harm
2023-05-18
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 2023-07-01
F · Potential for more than minimal harm
2023-05-18
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-01
F · Potential for more than minimal harm
2023-05-18
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-07-01
E · Potential for more than minimal harm
2023-05-18
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-18
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-18
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-01
F · Potential for more than minimal harm
2021-09-30
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2021-11-14
F · Potential for more than minimal harm
2021-09-30
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 2021-11-14
E · Potential for more than minimal harm
2021-09-30
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2021-11-14
E · Potential for more than minimal harm
2021-09-30
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2021-11-14
D · Potential for more than minimal harm
2021-09-30
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-11-14
D · Potential for more than minimal harm
2021-09-30
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2021-11-14
D · Potential for more than minimal harm
2021-09-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-11-14
D · Potential for more than minimal harm
2021-09-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-11-14
D · Potential for more than minimal harm
2021-09-30
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2021-11-14
D · Potential for more than minimal harm
2021-09-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-11-14
D · Potential for more than minimal harm
2021-09-30
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 2021-11-14
D · Potential for more than minimal harm
2021-09-30
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-11-14
D · Potential for more than minimal harm
2021-09-30
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 2021-11-14
D · Potential for more than minimal harm
2021-09-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-11-14
D · Potential for more than minimal harm
2021-09-30
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-11-14
D · Potential for more than minimal harm
2021-09-30
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-11-14
Penalties and ownership
What sits behind the stars
$26,618
2025-01-08
Fine
Fine · fine $26,618
Fine
$13,042
2024-05-16
Fine
Fine · fine $13,042
Fine
$16,801
2024-01-10
Fine
Fine · fine $16,801
Fine
$13,641
2023-09-26
Fine
Fine · fine $13,641
Fine
$4,194
2023-09-11
Fine
Fine · fine $4,194
Fine
Ownership
Westview Of Derby Property LLC
5% Or Greater Direct Ownership Interest · Organization
Tutera Group, Inc
5% Or Greater Direct Ownership Interest · Organization
Tutera, Joseph
5% Or Greater Direct Ownership Interest · Individual
Brooks, Kiley
Operational/Managerial Control · Individual
Brooks, Kiley
Corporate Officer · Individual
Walnut Creek Management Company LLC
Operational/Managerial Control · Organization
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#3
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