Inspection Reports for Derby Health &Amp; Rehabilitation LLC
731 KLEIN CIRCLE, KS, 67037
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 13, 2014, found that all previously cited deficiencies had been corrected. Earlier inspections identified multiple deficiencies related to resident dignity, medically related services, care planning, infection control, staffing, and food safety. Complaint investigations from 2012 found issues with comprehensive assessments, care planning, treatment for limited range of motion, and medication monitoring, but these were addressed in subsequent plans of correction. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s inspection history shows improvement over time, with the most recent revisit confirming compliance with regulatory standards.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
15.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
162% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
72 residents
Based on a December 2013 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 0
Feb 13, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of 01/17/2014, indicating compliance with the required standards.
Report Facts
Deficiencies corrected: 20
Date of revisit: Feb 13, 2014
Date of prior survey: Dec 19, 2013
Inspection Report
Plan of Correction
Deficiencies: 19
Jan 17, 2014
Visit Reason
This document is the facility's Plan of Correction responding to findings from a prior inspection by the Kansas Department on Ageing and Disability at Derby Health and Rehabilitation.
Findings
The Plan of Correction outlines multiple deficiencies identified in the facility related to dignity of residents, medically related services, housekeeping, sound levels, care planning, dialysis care, personal hygiene, skin breakdown, catheter care, accident investigations, nutrition, medication monitoring, staffing, food safety, hair restraint, pharmacy consultant reviews, medication labeling, infection control, and quality assurance. The facility describes corrective actions including policy reviews, staff in-services, monitoring by directors, and quality assurance processes to ensure substantial compliance.
Severity Breakdown
D: 8
E: 6
F: 5
Deficiencies (19)
| Description | Severity |
|---|---|
| Deficiency related to dignity of residents regarding knocking before entering rooms and cell phone use during care | E |
| Deficiency related to medically related services and assistance with obtaining discounted dentures | D |
| Deficiency related to housekeeping and maintenance services including personal effects identification | E |
| Deficiency related to comfortable sound levels and noise during meals | E |
| Deficiency related to care planning and updating care plans | E |
| Deficiency related to care of residents receiving hemodialysis and communication with dialysis centers | D |
| Deficiency related to personal hygiene including shaving and oral care | D |
| Deficiency related to care of residents with skin breakdown and repositioning | D |
| Deficiency related to care of residents with indwelling catheters to prevent urinary tract infections | D |
| Deficiency related to accidents and incidents root cause analysis and care planning | D |
| Deficiency related to planned nutritional supplements and maintaining good nutrition | D |
| Deficiency related to unnecessary medications and monitoring behaviors of residents receiving antipsychotics | D |
| Deficiency related to staffing patterns and time management | F |
| Deficiency related to safe and proper food temperatures | E |
| Deficiency related to restraining hair of all types for employees | E |
| Deficiency related to pharmacy consultant review of records and medication monitoring | D |
| Deficiency related to pharmaceutical system for labeling and discarding expired medications | F |
| Deficiency related to infection control, dressing changes, and housekeeping practices | F |
| Deficiency related to Quality Assurance and Performance Improvement (QAPI) program | F |
Inspection Report
Census: 72
Deficiencies: 18
Dec 19, 2013
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements and investigate complaints related to resident care, social services, housekeeping, sound levels, care planning, and other quality of care issues.
Findings
The facility was found deficient in multiple areas including failure to provide dignified care, medically-related social services, housekeeping and maintenance, sound level management, individualized care planning, provision of necessary care and services, nutritional supplement administration, monitoring of psychoactive medications, sufficient staffing, food safety and sanitation, medication labeling and expiration management, infection control practices, and quality assurance program effectiveness.
Severity Breakdown
SS=F: 4
SS=E: 7
SS=D: 6
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to provide dignified care including knocking before entering rooms, explaining treatments, and refraining from using cell phones while feeding residents. | SS=E |
| Failure to provide medically-related social services to assist a resident with obtaining dentures. | SS=D |
| Failure to provide housekeeping and maintenance services to distinguish personal toiletries and washcloths in semi-private rooms. | SS=E |
| Failure to maintain comfortable sound levels during meals, causing residents to raise their voices to socialize. | SS=E |
| Failure to develop specific, individualized care plans for residents involving dental hygiene, targeted behaviors, Foley catheter care, sleeping arrangements, and dialysis shunt monitoring. | SS=E |
| Failure to provide necessary daily monitoring and communication with dialysis center for a resident receiving dialysis. | SS=D |
| Failure to provide nail care, facial hair grooming, and oral care for residents requiring assistance. | SS=D |
| Failure to provide timely repositioning for a resident with pressure ulcers, risking delayed healing and new sores. | SS=E |
| Failure to provide appropriate care and services to prevent urinary tract infections for residents with indwelling catheters, including improper catheter bag handling and lack of catheter care. | SS=D |
| Failure to determine root causes of falls and develop effective interventions to prevent additional falls for residents with multiple falls. | SS=D |
| Failure to ensure a resident received a nutritional supplement as ordered and to document intake. | SS=D |
| Failure to identify and monitor specific behaviors related to psychoactive medications for residents, including lack of behavior monitoring sheets and targeted behavior documentation. | SS=D |
| Failure to label medications properly, discard expired medications, and store insulin pens according to manufacturer recommendations. | SS=F |
| Failure to ensure dietary staff wore proper hair restraints and served uncontaminated food. | SS=D |
| Failure to follow infection control policies including changing gloves between wound sites and during perineal care to prevent cross-contamination. | SS=F |
| Failure to maintain a quality assessment and assurance committee that effectively identified and addressed quality of care and quality of life deficiencies. | SS=F |
| Failure to provide sufficient nursing staff to meet resident care needs and supervision requirements. | SS=D |
| Failure to maintain proper food holding temperatures for resident meals. | SS=E |
Report Facts
Facility census: 72
Sample size: 23
Deficiency counts: 16
Medication doses: 17
Medication doses: 6
Food temperature: 108
Food temperature: 107
Food temperature: 99
Weight: 140
Albumin level: 2.3
Pressure ulcer size: 4
Pressure ulcer size: 3
Pressure ulcer size: 4
Pressure ulcer size: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nurse W | Licensed Nurse | Named in findings related to dignified care, catheter care, and infection control |
| Direct care staff B | Named in findings related to dignified care, catheter care, and infection control | |
| Direct care staff LL | Named in findings related to dignified care, nail care, and resident care | |
| Direct care staff T | Named in findings related to dignified care and catheter care | |
| Direct care staff U | Named in findings related to dignified care and catheter care | |
| Direct care staff S | Named in findings related to resident care and staffing | |
| Licensed nurse A | Administrative Nurse | Named in findings related to dignified care and quality assurance |
| Licensed nurse KK | Licensed Nurse | Named in findings related to dignified care, nail care, catheter care, and staffing |
| Licensed nurse P | Administrative Nurse | Named in findings related to dignified care, care planning, and medication monitoring |
| Licensed nurse O | Administrative Nurse | Named in findings related to dignified care, care planning, and medication monitoring |
| Licensed nurse FF | Licensed Nurse | Named in findings related to staffing and resident care |
| Licensed nurse EE | Licensed Nurse | Named in findings related to catheter care and medication monitoring |
| Licensed nurse Y | Licensed Nurse | Named in findings related to medication monitoring and infection control |
| Consultant pharmacist QQ | Consultant Pharmacist | Named in findings related to medication monitoring and pharmaceutical system |
| Dietary staff E | Named in findings related to food temperature and hair restraint | |
| Dietary staff BB | Named in findings related to hair restraint | |
| Housekeeping staff CC | Named in findings related to cleaning and disinfectant use |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 30, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies have been corrected as indicated in the prior CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit report confirms that all previously identified deficiencies, including those related to regulations 483.20(b)(1), 483.20(d), 483.20(k)(1), 483.25(e)(2), 483.25(l), and 483.60(c), were corrected as of the revisit date.
Report Facts
Deficiencies corrected: 6
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 5
Sep 7, 2012
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #56085, #57688, and #56668 to assess compliance with regulatory requirements.
Findings
The facility failed to conduct accurate comprehensive assessments for residents, develop comprehensive care plans including coordination with hospice care, provide appropriate treatment to prevent decrease in range of motion, adequately monitor blood sugars, and ensure pharmacist reporting of medication irregularities.
Complaint Details
The visit included complaint investigations #56085, #57688, and #56668 as part of the Health Resurvey.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to conduct accurate comprehensive assessments in dental and community discharge for 2 residents. | SS=D |
| Failed to develop comprehensive care plans for 2 residents including coordination with hospice care. | SS=D |
| Failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease. | SS=D |
| Failed to ensure drug regimen was free from unnecessary drugs by inadequately monitoring blood sugars of a resident receiving insulin. | SS=D |
| Pharmacist failed to report inadequate monitoring of elevated blood sugars to director of nursing. | SS=D |
Report Facts
Residents sampled: 28
Blood sugar readings: 426
Blood sugar readings: 404
Blood sugar readings: 358
Blood sugar readings: 395
Blood sugar readings: 449
Blood sugar readings: 423
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse L | Reported resident #89 refused to wear right elbow brace and staff had not documented education or notified Occupational Therapy. | |
| Nurse A | Licensed Nurse | Reported staff provided all cares for resident #121 and that pharmacist had not addressed inadequate blood sugar monitoring. |
| Staff D | Administrative Staff | Confirmed comprehensive assessments and care plans should be completed for each resident and hospice care coordination was lacking. |
| Physician Assistant K | Reported resident #169 continued to decline despite therapy leading to discharge to long term care. | |
| Social Services C | Reported resident #169 condition declined and spouse could not care for resident leading to discharge to LTC. | |
| Direct Care Staff B | Reported resident #73 had dentures but did not wear top dentures and could clean bottom teeth with assistance. | |
| Direct Care Staff G | Reported providing care to resident #121 except showers which were provided by hospice staff. | |
| Hospice Nurse F | Reported resident #121 was on hospice for congestive heart failure and neurogenic bladder. | |
| Licensed Staff M | Observed checking blood sugar of resident #89. |
Inspection Report
Plan of Correction
Deficiencies: 5
Sep 5, 2012
Visit Reason
The document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, addressing issues related to resident assessments, care plans, treatment of limited range of motion, and medication management.
Findings
The facility identified deficiencies in comprehensive resident assessments, care planning, treatment of residents with limited range of motion, and ensuring drug regimens are free from unnecessary medications. The Plan of Correction outlines corrective actions including audits, staff education, and monitoring to achieve compliance.
Severity Breakdown
D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to conduct comprehensive, accurate, standardized assessments of each resident's functional capacity. | D |
| Failure to use assessment results to develop, review, and revise comprehensive care plans. | D |
| Failure to ensure residents with limited range of motion receive appropriate treatment and services. | D |
| Failure to ensure each resident's drug regimen is free from unnecessary drugs. | D |
| Failure to ensure pharmacist reports irregularities to attending physician and director of nursing and that these reports are acted upon. | D |
Report Facts
Deficiencies cited: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Thomas Broderick | Administrator | Submitted the Plan of Correction |
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