Inspection Reports for
Derby Assisted Living LLC
719 N KLEIN CIRCLE, DERBY, KS, 67037-
Back to Facility ProfileDeficiencies (last 7 years)
Deficiencies (over 7 years)
1.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% better than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
100% occupied
Based on a April 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 13, 2026
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2026-04-21.
Findings
All deficiencies have been corrected as of the compliance date of 2026-05-13, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: May 13, 2026
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2026-04-21.
Findings
All deficiencies have been corrected as of the compliance date of 2026-05-13, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Census: 35
Deficiencies: 4
Date: Apr 21, 2026
Visit Reason
The inspection was a Re-Licensure Survey conducted for the assisted living facility to assess compliance with licensing requirements.
Findings
The survey identified multiple deficiencies including incomplete negotiated service agreements for residents, lack of documentation of incidents and follow-up on treatments, and failure to comply with tuberculosis screening guidelines for newly hired employees.
Deficiencies (4)
KAR 26-41-202(a) The facility failed to ensure negotiated service agreements included all required service descriptions, providers, and payment responsibilities for one resident.
KAR 26-41-202(c) The facility failed to ensure an initial negotiated service agreement was completed at admission for one resident.
KAR 26-41-105(f)(11) The facility failed to document all incidents, symptoms, and indications of illness or injury, including actions taken and results, for three residents.
KAR 26-41-207(b)(5-6)(c) The facility failed to comply with tuberculosis screening guidelines for three of five newly hired employees.
Report Facts
Resident census: 35
Sampled residents: 3
Newly hired employees reviewed: 5
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-10-02.
Findings
All previously cited deficiencies have been corrected as of the compliance date of 2024-10-17 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2024-10-02.
Findings
All deficiencies cited in the prior inspection have been corrected as of the compliance date of 2024-10-17. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
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 at Avita Senior Living at Derby.
Complaint Details
The inspection was conducted with an attached complaint number 190037.
Findings
The facility failed to ensure proper delegation and competency for insulin pen preparation by Certified Medication Aides, failed to assess and document safe use of a bed assist device for a resident, failed to complete required assessments for residents self-administering medications, failed to document all incidents and symptoms in resident records, and lacked a comprehensive emergency management plan including missing residents.
Deficiencies (5)
KAR 26-41-204(e) The administrator failed 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.
K.A.R. 26-41-204(i) The administrator failed to assess a resident's bed assist device for safety, restraint status, secure attachment, and resident's ability to use it safely.
K.A.R. 26-41-205(a)(1) The operator failed to ensure Licensed Nurse completed initial and annual assessments for residents self-administering medications including insulin and topical creams.
K.A.R. 26-41-105(f)(11) The operator failed to ensure resident records contained documentation of all incidents, symptoms, actions taken, and results for residents R1 and R2.
K.A.R. 26-41-104(b) The operator failed to develop a detailed written emergency management plan including the topic of missing residents.
Report Facts
Resident census: 32
Residents receiving insulin injections: 5
Certified Medication Aides: 4
Residents in sample: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 1, 2024
Visit Reason
The document is a plan of correction responding 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 found during the licensure resurvey and complaint investigation conducted on the specified dates.
Inspection Report
Re-Inspection
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 cited in the prior inspection have been corrected as of the compliance date of 2023-02-20. No new noncompliance was found and the facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
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 cited in the prior inspection 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 8, 2023
Visit Reason
The inspection was a resurvey with an attached complaint #166871 at the assisted living facility conducted 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 develop accurate negotiated service agreements for residents based on their functional capacity screenings. Additionally, the facility did not ensure proper destruction of deteriorated, outdated, or discontinued medications by required licensed personnel.
Deficiencies (2)
KAR 26-41-202(a)(1)(2)(3) The administrator failed to ensure the development of negotiated service agreements for residents that accurately reflected their functional capacity and identified services, providers, and payment responsibilities.
KAR 26-41-205(i)(1)(A)(B) The operator failed to ensure that deteriorated, outdated, or discontinued controlled medications were destroyed by two licensed nurses or a licensed nurse and a licensed pharmacist.
Report Facts
Residents census: 28
Residents taking controlled medications: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse B | Administrative Nurse | Confirmed that controlled medications were not properly disposed of. |
| Certified Medication Aide C | Certified Medication Aide | Observed unlocking and opening the medication cart containing medications. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 7, 2023
Visit Reason
This document is a plan of correction submitted in response to a resurvey with an attached complaint #166871 conducted at the assisted living facility on 02/07/23 - 02/08/23.
Complaint Details
The visit was related to complaint #166871 attached to the resurvey.
Findings
The plan of correction addresses citations found during the resurvey and complaint investigation conducted on the specified dates.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 18, 2020
Visit Reason
The facility underwent a special infection control survey for COVID-19.
Findings
The survey conducted on 2020-06-18 resulted in findings of no deficiency citations.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 27, 2018
Visit Reason
The visit was a resurvey of the assisted living facility to verify compliance after a previous 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 visit was a resurvey 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 at the facility.
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 14, 2015
Visit Reason
The licensure resurvey with investigation of complaints #81829, #81058, and #79825 was conducted at the assisted living facility on 1/12/15, 1/13/15, and 1/14/15.
Complaint Details
The visit was complaint-related involving complaints #81829, #81058, and #79825. No deficiencies were cited.
Findings
The investigation and licensure resurvey resulted in no deficiency citations being found at the facility.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087066 POC 06CJ11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for a regulated facility.
Findings
No specific deficiencies or findings are detailed in this document. It references a prior deficiency report but contains no records or corrective details.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087066 POC AVG911
Visit Reason
This document is a plan of correction related to a prior deficiency report for the facility Avita Senior Living at Derby.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or reference to a plan of correction linked to a previous deficiency report.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087066 POC CRLN11
Visit Reason
This document is a Plan of Correction related to a previously identified deficiency report for the facility.
Findings
No deficiency details or findings are included in this document. It only references the Plan of Correction status and contact information for assistance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087066 POC L6PC11
Visit Reason
This document is a plan of correction related to a prior deficiency report for Avita Senior Living at Derby concerning a COVID-19 related inspection.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a placeholder or administrative record for the plan of correction submission.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087066 POC P9OZ11
Visit Reason
This document is a Plan of Correction related to a prior deficiency report for Avita Senior Living at Derby.
Findings
No specific findings or deficiencies are detailed in this document. It serves as a record of the Plan of Correction submission and modification dates.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087066 POC U1YQ11
Visit Reason
This document is a Plan of Correction related to a prior inspection event for the facility identified by State ID N087066 and Event ID U1YQ11.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Viewing
Loading inspection reports...
