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Derby Health & Rehabilitation Llc

Details

Type of Ownership For profit - Corporation
Participates in Medicare? Yes
Participates in Medicaid? Yes
Certified Beds 74
Continuing Care? No
Resident Council? Yes
Family Council? No
Multi-Home Chain? No
Located in a Hospital? No
Special Focus Facility? No

View:    Health Inspections  |  Quality Measures  |  Staffing  |  Fire Inspections

Health Inspections  

Most Recent Inspection: 05/19/2011

Date of last standard health inspection: 05/19/2011
Quality Indicator Survey No
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Health Deficiencies for this nursing home: 1
Average number of Health Deficiencies in KS: 4
Average number of Health Deficiencies in US: 3
Range of Health Deficiencies in KS: 0 - 18
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Immediately tell the resident 01/09/2012 02/01/2001 and a family member of situations (injury/decline/ the resident's doctor

Inspection, 00/09/2009

Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide timely notification to the resident before transfer or discharge. 00/09/2009 01/04/2009 2 Few

Inspection, 00/07/2009

Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 00/07/2009 03/00/2009 2 Few
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. 00/07/2009 03/00/2009 2 Few
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 00/07/2009 03/00/2009 2 Few
At least once a month 00/07/2009 03/00/2009 Few have a licensed pharmacist review each resident's
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. 00/07/2009 03/00/2009 2 Few
Have enough nurses to care for every resident in a way that maximizes the resident's well being. 00/07/2009 00/00/0000 2 Some
Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. 00/07/2009 03/00/2009 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Conduct initial and periodic assessments of each resident's functional capacity. 00/07/2009 03/00/2009 2 Few
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 00/07/2009 03/00/2009 2 Few
Conduct initial and periodic assessments of each resident's functional capacity. 00/07/2009 03/00/2009 2 Few
Develop a complete care plan that meets all the resident's needs 00/07/2009 03/00/2009 Few with timetables and actions that can be measured.

Inspection, 00/02/2008

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly 00/02/2008 03/00/2008 Many and develop corrective plans of action.
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. 00/02/2008 03/00/2008 2 Some

Inspection, 01/09/2007

Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 01/09/2007 00/00/0000 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide necessary care and services to maintain or improve the highest well being of each resident. 01/09/2007 00/00/0000 2 Few

Inspection, 01/07/2006

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate 01/07/2006 00/02/2008 Few complete and organized clinical records on each re
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly 01/07/2006 03/00/2008 Many and develop corrective plans of action.
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/07/2006 00/02/2008 2 Few
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people with no legal history of abusing 01/07/2006 00/02/2008 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Allow residents the right to participate in the planning or revision of care and treatment. 01/07/2006 00/02/2008 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. 01/07/2006 00/02/2008 2 Few

Inspection, 01/09/2005

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. 01/09/2005 02/03/2009 2 Many
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/09/2005 00/07/2009 2 Few
Make sure that a working call system is available in each resident's room or bathroom and bathing area. 01/09/2005 01/09/2007 2 Some
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/09/2005 01/00/2006 2 Few
Make sure that a working call system is available in each resident's room or bathroom and bathing area. 01/09/2005 01/00/2006 2 Some
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. 01/09/2005 01/09/2007 2 Some
Store, cook, and serve food in a safe and clean way. 01/09/2005 01/09/2007 2 Many
Store 01/09/2005 01/00/2006 and serve food in a safe and clean way. cook
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 01/09/2005 02/03/2009 2 Some
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. 01/09/2005 00/07/2009 2 Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 01/09/2005 01/09/2007 2 Some
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 01/09/2005 01/00/2006 2 Some
Keep the rate of medication errors (wrong drug 01/09/2005 01/00/2006 wrong time) to less than 5%. wrong dose
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. 01/09/2005 01/00/2006 2 Some
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide necessary care and services to maintain or improve the highest well being of each resident. 01/09/2005 00/07/2009 2 Few
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. 01/09/2005 01/09/2007 2 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 01/09/2005 01/09/2007 2 Few
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. 01/09/2005 01/09/2007 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 01/09/2005 01/00/2006 2 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 01/09/2005 01/00/2006 2 Few
Ensure that each resident who enters the nursing home without a catheter is not given a catheter 01/09/2005 01/00/2006 and that incontinent patients receive proper servi unless medically necessary
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Conduct initial and periodic assessments of each resident's functional capacity. 01/09/2005 00/07/2009 2 Few
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 01/09/2005 00/07/2009 2 Few
Allow residents the right to participate in the planning or revision of care and treatment. 01/09/2005 00/07/2009 2 Few
Conduct initial and periodic assessments of each resident's functional capacity. 01/09/2005 01/00/2006 2 Few
Develop a complete care plan that meets all the resident's needs 01/09/2005 01/00/2006 Few with timetables and actions that can be measured.
Allow residents the right to participate in the planning or revision of care and treatment. 01/09/2005 01/00/2006 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give residents a notice of rights, rules, services and charges. 01/09/2005 01/09/2007 1 Many
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 01/09/2005 01/09/2007 2 Few
Allow residents to easily view the results of the nursing home's most recent inspection. 01/09/2005 01/09/2007 1 Many
Permit residents to remain in the facility and not be transferred or discharged without adequate reason. 01/09/2005 01/09/2007 2 Few
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 01/09/2005 01/09/2007 2 Some
Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. 01/09/2005 01/09/2007 2 Few
Give residents a notice of rights 01/09/2005 01/00/2006 services and charges. rules
Immediately tell the resident 01/09/2005 01/00/2006 and a family member of situations (injury/decline/ the resident's doctor
Allow residents to easily view the results of the nursing home's most recent inspection. 01/09/2005 01/00/2006 1 Many
Permit residents to remain in the facility and not be transferred or discharged without adequate reason. 01/09/2005 01/00/2006 2 Few
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 01/09/2005 01/00/2006 2 Some
Ensure residents have the right to have a choice over activities 01/09/2005 01/00/2006 and health care according to their interests their schedules

Inspection, 00/04/2005

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/04/2005 01/08/2005 2 Few
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people with no legal history of abusing 00/04/2005 01/02/2005 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Have enough nurses to care for every resident in a way that maximizes the resident's well being. 00/04/2005 01/04/2005 2 Many

Inspection, 00/09/2002

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Have a program that investigates, controls and keeps infection from spreading. 00/09/2002 01/02/2002 2 Many
Have a program that investigates 00/09/2002 01/02/2002 Many controls and keeps infection from spreading.
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. 00/09/2002 01/02/2002 2 Few
1) Hire only people with no legal history of abusing 00/09/2002 01/02/2002 neglect or mistreatment of residents. neglecting or mistreating residents; or 2) report
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Store, cook, and serve food in a safe and clean way. 00/09/2002 01/02/2002 2 Many
Store 00/09/2002 01/02/2002 and serve food in a safe and clean way. cook
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 00/09/2002 01/02/2002 2 Some
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 00/09/2002 01/02/2002 2 Few
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. 00/09/2002 01/02/2002 2 Some
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 00/09/2002 01/02/2002 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 00/09/2002 01/02/2002 2 Few
Ensure residents maintain acceptable nutritional status. 00/09/2002 01/02/2002 2 Few
Develop policies and procedures for influenza and pneumococcal immunizations. 00/09/2002 01/02/2002 2 Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 00/09/2002 01/02/2002 2 Few
Ensure residents maintain acceptable nutritional status. 00/09/2002 01/02/2002 2 Few
Develop policies and procedures for influenza and pneumococcal immunizations. 00/09/2002 01/02/2002 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Allow residents the right to participate in the planning or revision of care and treatment. 00/09/2002 01/02/2002 2 Some
Allow residents the right to participate in the planning or revision of care and treatment. 00/09/2002 01/02/2002 2 Some

Nursing Home Staffing  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

National Average Average in KS Golden Living Center, Asheville
RN Staff Only1 N/A N/A 5 out of 5 stars
Total Number of Residents 86 52 67
Total, Licensed Nurse Staff Hours
per Resident per Day
16 hours 51 minutes 19 hours 26 minutes 1 hour 51 minutes
RN Hours
per Resident per Day
16 hours 3 minutes 18 hours 49 minutes 1 hour 10 minutes
LPN/LVN Hours
per Resident per Day
16 hours 17 minutes 18 hours 48 minutes 42 minutes
CNA Hours
per Resident per Day
17 hours 46 minutes 20 hours 45 minutes 2 hours 18 minutes

1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.

Quality Measures  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

Long-Term Residents

Short-Term Residents

Fire Safety Inspections

Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.

Most Recent Inspection: 11/10/2010

Automatic Sprinkler Systems in all required areas Yes
Date of last standard fire safety inspection: 11/10/2010
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Fire Safety Deficiencies for this nursing home: 0
Average number of Fire Safety Deficiencies in KS: 2
Average number of Fire Safety Deficiencies in US: 2
Range of Fire Safety Deficiencies in KS: 0 - 2

Inspection, 01/00/2011

Fire Alarm Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
An approved installation, maintenance and testing program for fire alarm systems. 01/00/2011 01/09/2011 2 Many
Illumination and Emergency Power Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Emergency lighting that can last at least 1 1/2 hours. 01/00/2011 01/09/2011 2 Few

Inspection, 00/05/2001

Building Service Equipment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Properly protected cooking facilities. 00/05/2001 01/05/2001 2 Some
Illumination and Emergency Power Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Emergency lighting that can last at least 1 1/2 hours. 00/05/2001 01/05/2001 2 Some
 

731 Klein Circle
Derby, KS 67037

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