Inspection Reports for Derby Assisted Living LLC
719 N KLEIN CIRCLE, DERBY, KS, 67037-
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 17, 2024, found the facility in compliance with all regulations and no new deficiencies. Earlier in October 2024, inspectors cited issues including inadequate training and delegation for medication aides, incomplete resident assessments, insufficient documentation, and an emergency management plan lacking provisions for missing residents. Prior inspections noted deficiencies related to service agreements and medication destruction documentation, but no fines or enforcement actions were listed in the available reports. Complaint investigations were attached to some inspections, with deficiencies substantiated in the October 2024 and February 2023 surveys, while earlier complaints were unsubstantiated. The facility appears to have addressed prior deficiencies effectively, as shown by the most recent clean follow-up inspection.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
1.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
80% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
32 residents
Based on a October 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
An offsite revisit survey was conducted on 10/17/24 to verify correction of all previous deficiencies cited on 10/02/24.
Findings
All deficiencies have been corrected as of the compliance date of 10/17/24 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 32
Deficiencies: 5
Date: Oct 2, 2024
Visit Reason
The inspection was a licensure resurvey with an attached complaint number 190037 conducted on 10/01/24 and 10/02/24 to assess compliance with state regulations for Avita Senior Living at Derby.
Complaint Details
The inspection included an attached complaint number 190037.
Findings
The facility was found deficient in multiple areas including failure to ensure proper delegation and training of Certified Medication Aides for insulin pen preparation, lack of assessment and secure attachment of a bed assist device for a resident, incomplete assessments for residents self-administering medications, inadequate documentation of incidents and symptoms in resident records, and an incomplete emergency management plan lacking provisions for missing residents.
Deficiencies (5)
Failure to ensure four newly hired Certified Medication Aides were trained and delegated by a Licensed Nurse to prepare and dial insulin pens for resident self-injection.
Failure to provide healthcare services in accordance with professional standards by not assessing a resident's bed assist device for safety, restraint status, and secure attachment.
Failure to complete required assessments for residents self-administering medications to ensure safe and accurate self-administration.
Failure to document all incidents, symptoms, and indications of illness or injury including date, time, actions taken, and results in resident records.
Failure to develop a detailed written emergency management plan including all required emergency situations, specifically lacking a plan for missing residents.
Report Facts
Census: 32
Residents receiving insulin injections: 5
Certified Medication Aides: 4
Residents in sample: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Operator A | Interviewed and confirmed deficiencies related to delegation, assessments, and emergency plan. | |
| Licensed Nurse B | Licensed Nurse | Interviewed and confirmed lack of delegation, assessments, and documentation. |
| Regional Vice President D | Regional Vice President | Confirmed bed assist device was not securely attached to resident's bed. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 1, 2024
Visit Reason
The document is a plan of correction submitted in response to findings from a licensure resurvey with an attached complaint number 190037 conducted on October 1 and 2, 2024.
Complaint Details
The inspection was conducted with an attached complaint number 190037.
Findings
The plan of correction addresses citations identified during the licensure resurvey and complaint investigation conducted on the specified dates.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 20, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-02-08.
Findings
All deficiencies have been corrected as of the compliance date of 2023-02-20, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Census: 28
Deficiencies: 2
Date: Feb 7, 2023
Visit Reason
The inspection was a resurvey with an attached complaint #166871 conducted at Avita Senior Living at Derby on 02/07/23 - 02/08/23.
Complaint Details
The inspection was conducted as a resurvey with an attached complaint #166871.
Findings
The facility failed to ensure the development of negotiated service agreements (NSA) for residents based on their functional capacity screenings, and failed to properly document the destruction of deteriorated, outdated, or discontinued medications by required licensed personnel.
Deficiencies (2)
Failure to develop a negotiated service agreement for residents based on their functional capacity screening, including description of services, provider identification, and payment responsibility.
Failure to maintain records documenting the destruction of deteriorated, outdated, or discontinued controlled medications by two licensed nurses or a licensed nurse and a licensed pharmacist.
Report Facts
Census: 28
Residents taking controlled medications: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Confirmed that controlled medications that had become deteriorated, outdated, or discontinued were not disposed of by two licensed nurses or a licensed nurse and licensed pharmacist. |
| Certified Medication Aide C | Certified Medication Aide | Observed unlocking and opening the medication cart containing medications for residents. |
| Administrative Staff A | Administrative Staff | Confirmed that residents' negotiated service agreements were not based on functional capacity screenings and failed to identify required service details. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 7, 2023
Visit Reason
This document is a plan of correction related to a resurvey with an attached complaint #166871 conducted at an assisted living facility on 02/07/23 - 02/08/23.
Complaint Details
The plan of correction is related to complaint #166871 attached to the resurvey.
Findings
The citations represent findings from the resurvey and complaint investigation conducted during the specified dates.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 18, 2020
Visit Reason
The special infection control survey for COVID-19 was conducted at the facility on 6-18-2020.
Findings
The survey resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 27, 2018
Visit Reason
The visit was a resurvey at the assisted living facility to verify compliance following a prior inspection.
Findings
The resurvey conducted on 08/27/2018 resulted in zero citations, indicating no deficiencies were found.
Report Facts
Citations: 0
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jan 5, 2017
Visit Reason
The resurvey at the facility was conducted on January 3, 4, and 5, 2017 to verify correction of previous deficiencies.
Findings
The resurvey resulted in a finding of no deficiency citations.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 14, 2015
Visit Reason
The licensure resurvey with investigation of complaints #81829, #81058, and #79825 of the assisted living facility occurred on 1/12/15, 1/13/15, and 1/14/15.
Complaint Details
The visit was complaint-related involving complaints #81829, #81058, and #79825, with no deficiencies found.
Findings
The investigation and licensure resurvey resulted in no deficiency citations being found.
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