Inspection Reports for
Derby Health &Amp; Rehabilitation LLC
731 KLEIN CIRCLE, DERBY, KS, 67037
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
12.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
93% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 2
Date: Apr 29, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure an environment free from accident hazards and provide adequate supervision during mechanical lift transfers.
Complaint Details
The complaint investigation found that staff failed to maintain hands-on contact with residents during mechanical lifts, increasing risk of accidents. The complaint was substantiated with observations and staff interviews confirming unsafe practices.
Findings
The facility failed to ensure adequate hands-on stabilization during full body mechanical lift transfers for two residents, placing them at risk for accidents and injuries. Staff members released physical control of residents during lifts, contrary to safety protocols, and the facility's mechanical lift policy lacked documentation on proper positioning and resident safety measures.
Deficiencies (2)
F 0689: The facility failed to ensure an environment free from accident hazards by not providing adequate hands-on stabilization during mechanical lift transfers for two residents. Staff released physical control during lifts, risking resident safety.
The facility's mechanical lift policy lacked documentation on positioning of the lift legs and staff responsibilities to maintain resident safety during lift operation.
Report Facts
Residents present: 69
Residents reviewed: 7
Residents reviewed for accident hazards: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA G | Certified Medication Aide | Operated mechanical lift controls and involved in deficient lift transfer |
| CNA H | Certified Nurse Aide | Released physical control during lift transfer, involved in deficient practice |
| CNA E | Certified Nurse Aide | Operated mechanical lift controls during deficient lift transfer |
| CNA F | Certified Nurse Aide | Released physical control during lift transfer, involved in deficient practice |
| LN D | Licensed Nurse | Provided interview confirming proper mechanical lift operation standards |
| Administrative Nurse B | Administrative Nurse | Provided interview on mechanical lift operation and policy deficiencies |
Inspection Report
Routine
Census: 61
Deficiencies: 7
Date: Apr 30, 2024
Visit Reason
Routine inspection of Derby Health & Rehabilitation, LLC to assess compliance with Medicare and Medicaid regulations and facility policies.
Findings
The facility failed to provide correct Medicare ABN forms to residents, ensure medication security preventing misappropriation, safely store hazardous chemicals, provide proper G-tube care, hold blood pressure medication per physician orders, and maintain sanitary food handling and storage practices.
Deficiencies (7)
F 0582: The facility failed to provide residents R8, R11, and R160 the correct CMS Form 10055 ABN, placing them at risk of uninformed decisions about skilled services.
F 0602: The facility failed to protect residents from medication misappropriation when multiple residents' controlled medications were missing, placing residents at risk for abuse and impaired care.
F 0689: Hazardous chemicals were stored unlocked in a housekeeping closet, placing five cognitively impaired, independently mobile residents at risk for injury.
F 0693: The facility failed to flush resident R41's G-tube with 45 ml of water before nutritional feeding as ordered, placing the resident at risk for G-tube complications.
F 0756: The consultant pharmacist failed to identify and report administration of midodrine outside physician-ordered blood pressure parameters, placing resident R47 at risk for unnecessary medications and complications.
F 0757: Staff failed to hold resident R47's midodrine medication when systolic blood pressure exceeded 130 as ordered, placing the resident at risk for unnecessary drugs and related complications.
F 0812: The facility failed to store, prepare, and serve food in a sanitary manner in two kitchens and dining rooms, placing residents at risk for food-borne illness.
Report Facts
Residents affected: 61
Sample residents reviewed: 15
Missing oxycodone tablets: 12
Missing oxycodone-acetaminophen tablets: 20
Missing hydrocodone-acetaminophen tablets: 30
Water flush volume: 45
Midodrine dosage: 10
Midodrine administration frequency: 3
Residents affected by food sanitation issues: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Reported medication misappropriation and verified staff medication procedures | |
| Licensed Nurse H | Received narcotic medications and provided witness statement during investigation | |
| Consultant GG | Verified incorrect ABN form use and nursing staff G-tube care | |
| Certified Nurse Aide M | Observed serving food without hand hygiene | |
| Dietary Staff BB | Verified food storage and sanitation deficiencies | |
| Certified Medication Aide R | Administered midodrine to resident R47 despite elevated blood pressure | |
| Administrative Nurse E | Verified medication administration errors and consultant pharmacist review issues |
Inspection Report
Routine
Census: 61
Deficiencies: 7
Date: Apr 30, 2024
Visit Reason
Routine inspection of Derby Health & Rehabilitation, LLC to assess compliance with Medicare/Medicaid regulations and facility policies.
Findings
The facility failed to provide correct Medicare ABN forms to residents, ensure medication security preventing misappropriation, safely store hazardous chemicals, provide proper G-tube care, hold blood pressure medication per physician orders, and maintain sanitary food handling and storage practices.
Deficiencies (7)
F 0582: The facility failed to provide residents R8, R11, and R160 the correct Medicare ABN Form 10055, placing them at risk of uninformed decisions about skilled services.
F 0602: The facility failed to protect residents from medication misappropriation when multiple residents' narcotic medications were missing, placing residents at risk for abuse and impaired care.
F 0689: Hazardous chemicals were stored unlocked in a housekeeping closet, placing five cognitively impaired, mobile residents at risk for injury.
F 0693: The facility failed to flush resident R41's G-tube with 45 ml of water before nutritional feeding as ordered, placing the resident at risk for G-tube complications.
F 0756: The Consultant Pharmacist failed to identify and report administration of midodrine outside physician-ordered blood pressure parameters, placing resident R47 at risk for unnecessary medication complications.
F 0757: The facility failed to hold resident R47's blood pressure medication midodrine when systolic blood pressure exceeded 130, placing the resident at risk for unnecessary drugs and complications.
F 0812: The facility failed to serve food in a sanitary manner in two kitchens and dining rooms, including uncovered food and staff not washing hands, placing residents at risk for food-borne illness.
Report Facts
Residents affected: 3
Residents affected: 3
Residents affected: 5
Residents affected: 1
Residents affected: 1
Medication counts: 12
Medication counts: 20
Medication counts: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Administrative Nurse | Reported medication misappropriation and verified staff medication procedures. |
| Licensed Nurse H | Licensed Nurse | Received narcotic medications and provided witness statement during investigation. |
| Consultant GG | Consultant | Verified incorrect ABN form use and nursing staff medication administration errors. |
| Certified Medication Aide R | Certified Medication Aide | Administered midodrine medication to resident R47 despite elevated blood pressure. |
| Certified Nurse Aide M | Certified Nurse Aide | Observed serving food without hand hygiene and verified hazardous chemical storage findings. |
| Dietary Staff BB | Dietary Manager | Verified food storage and sanitation deficiencies. |
| Administrative Nurse E | Administrative Nurse | Verified medication administration errors and consultant pharmacist review failures. |
| Licensed Nurse G | Licensed Nurse | Observed administering G-tube feeding without proper water flush. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 12, 2023
Visit Reason
Annual inspection survey of Derby Health & Rehabilitation, LLC to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 69
Deficiencies: 4
Date: Nov 8, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident safety, catheter care, staffing, and medication labeling.
Findings
The facility was found deficient in multiple areas including failure to implement fall prevention interventions, inadequate catheter care leading to risk of urinary tract infections, inaccurate nurse staffing postings, and improper labeling and expiration dating of insulin pens.
Deficiencies (4)
F 0689: The facility failed to place a motion alarm pad under a cognitively impaired resident when moved from bed to recliner, resulting in a fall with facial bruising.
F 0690: The facility failed to ensure catheter tubing was kept off the floor for two residents, increasing risk of urinary tract infections.
F 0732: The facility failed to ensure daily nurse staffing postings accurately reflected actual hours worked by nursing staff.
F 0761: The facility failed to correctly label expiration dates on opened insulin pens and ensure one insulin pen had a pharmacy label as required.
Report Facts
Residents present: 69
Residents sampled: 20
Residents reviewed for falls: 4
Residents reviewed for urinary catheter/UTI: 3
Residents reviewed for insulin pen labeling: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Aide (CMA) R | Provided information about fall and motion alarm pad use | |
| Certified Nurse Aide (CNA) M | Confirmed expectation to keep motion alarm pad under resident and catheter tubing off floor | |
| Licensed Nurse (LN) G | Confirmed staff should have placed motion alarm pad and catheter tubing off floor | |
| Administrative Nurse D | Stated expectations for motion alarm pad placement and catheter tubing care | |
| Certified Nurse Aide (CNA) P | Confirmed catheter tubing sometimes lay on floor | |
| Licensed Nurse (LN) H | Confirmed catheter tubing should be kept off floor and discussed insulin pen labeling | |
| Administrative Nurse E | Discussed insulin pen labeling expectations and medication administration policy | |
| Administrative Staff A | Updated daily staff posting |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 12, 2021
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Derby Health & Rehabilitation, LLC.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Follow-Up
Deficiencies: 19
Date: Feb 13, 2014
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies had been corrected.
Findings
The report documents that all previously identified deficiencies were corrected by 01/17/2014 as verified during the revisit on 02/13/2014.
Deficiencies (19)
Regulation 483.15(a) deficiency identified by tag F0241 was corrected by 01/17/2014.
Regulation 483.15(g)(1) deficiency identified by tag F0250 was corrected by 01/17/2014.
Regulation 483.15(h)(2) deficiency identified by tag F0253 was corrected by 01/17/2014.
Regulation 483.15(h)(7) deficiency identified by tag F0258 was corrected by 01/17/2014.
Regulation 483.20(d), 483.20(k)(1) deficiency identified by tag F0279 was corrected by 01/17/2014.
Regulation 483.25 deficiency identified by tag F0309 was corrected by 01/17/2014.
Regulation 483.25(a)(3) deficiency identified by tag F0312 was corrected by 01/17/2014.
Regulation 483.25(c) deficiency identified by tag F0314 was corrected by 01/17/2014.
Regulation 483.25(d) deficiency identified by tag F0315 was corrected by 01/17/2014.
Regulation 483.25(h) deficiency identified by tag F0323 was corrected by 01/17/2014.
Regulation 483.25(i) deficiency identified by tag F0325 was corrected by 01/17/2014.
Regulation 483.25(l) deficiency identified by tag F0329 was corrected by 01/17/2014.
Regulation 483.30(a) deficiency identified by tag F0353 was corrected by 01/17/2014.
Regulation 483.35(d)(1)-(2) deficiency identified by tag F0364 was corrected by 01/17/2014.
Regulation 483.35(i) deficiency identified by tag F0371 was corrected by 01/17/2014.
Regulation 483.60(c) deficiency identified by tag F0428 was corrected by 01/17/2014.
Regulation 483.60(b), (d), (e) deficiency identified by tag F0431 was corrected by 01/17/2014.
Regulation 483.65 deficiency identified by tag F0441 was corrected by 01/17/2014.
Regulation 483.75(o)(1) deficiency identified by tag F0520 was corrected by 01/17/2014.
Inspection Report
Plan of Correction
Deficiencies: 19
Date: Jan 17, 2014
Visit Reason
This document is a Plan of Correction submitted by Derby Health and Rehabilitation in response to deficiencies cited by the Kansas Department on Ageing and Disability.
Findings
The facility identified multiple deficiencies related to dignity of residents, medically related services, housekeeping, sound levels, care planning, dialysis care, personal hygiene, skin care, catheter care, accident prevention, nutrition, medication monitoring, staffing, food safety, hair restraint, pharmacy consultant reviews, medication labeling and disposal, infection control, and quality assurance. Corrective actions and staff training plans were outlined for each deficiency.
Deficiencies (19)
F241-E: Deficiency in dignity of residents related to knocking before entering rooms, cell phone use, and permission prior to care. Staff will be trained and monitored.
F250-D: Deficiency in medically related services including assistance with obtaining discounted dentures and Medicaid liability information. Staff will be trained and monitored.
F253-E: Deficiency in housekeeping and maintenance services related to personal effects identification and bathroom towel holders. Staff will be trained and monitored.
F258-E: Deficiency in maintaining comfortable sound levels; staff will avoid vacuuming during meals and reduce noise. Staff training planned.
F279-E: Deficiency in care planning; care plans updated and staff training planned to ensure comprehensive care plans.
F309-D: Deficiency in care of residents receiving hemodialysis and communication with dialysis centers; care plans updated and staff training planned.
F312-D: Deficiency in personal hygiene care; issues corrected and staff training planned.
F314-D: Deficiency in care of residents with skin breakdown and repositioning; resident repositioned and staff training planned.
F315-D: Deficiency in care of residents with indwelling catheters to prevent UTIs; issues corrected and staff training planned.
F323-D: Deficiency in accident and incident management; root cause analysis done and staff training planned.
F325-D: Deficiency in administration of planned nutritional supplements; issues corrected and staff training planned.
F329-D: Deficiency in monitoring behaviors of residents receiving antipsychotics; issues corrected and staff training planned.
F353-F: Deficiency in staffing patterns and meeting resident needs; issues corrected and staff training planned.
F364-E: Deficiency in safe and proper food temperatures; dietary staff trained and records ensured compliance.
F371-E: Deficiency in restraining hair of all types; employees educated and staff training planned.
F428-D: Deficiency in pharmacy consultant review of records; staff trained on medication monitoring and assessments.
F431-F: Deficiency in pharmaceutical system for labeling and discarding expired medications; medications discarded and staff trained.
F441-F: Deficiency in infection control, dressing changes, and housekeeping practices; staff educated and training planned.
F520-F: Deficiency in QAPI and quality improvement; Quality Assurance Committee to review and develop PIPs, staff training planned.
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 19
Date: Dec 19, 2013
Visit Reason
Annual health resurvey and comprehensive inspection of Derby Health & Rehabilitation LLC to assess compliance with regulatory requirements.
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 plans, pressure ulcer care, urinary catheter care, nutrition, medication management, infection control, staffing sufficiency, food safety, and quality assurance program effectiveness.
Deficiencies (19)
F241 dignity and respect: Staff failed to knock and receive permission before entering resident rooms, failed to request permission for treatments, and used cell phones while feeding residents.
F250 medically-related social services: Facility failed to assist a resident with obtaining dentures due to lack of follow-up and cooperation with resident's durable power of attorney.
F253 housekeeping and maintenance: Facility failed to distinguish personal toiletries and washcloths in semi-private rooms, risking sanitary conditions for 20 residents.
F258 sound levels: Facility failed to maintain comfortable sound levels during meals, with vacuuming noise interfering with residents' social interaction in 3 of 4 dining rooms.
F279 comprehensive care plans: Facility failed to develop individualized care plans for 9 residents including dental care, behavior monitoring, catheter care, sleep preferences, and dialysis shunt monitoring.
F309 care and services: Facility failed to provide necessary daily monitoring and communication with dialysis center for a resident receiving dialysis.
F312 ADL care: Facility failed to provide nail care, facial hair grooming, and oral care for residents requiring assistance.
F314 pressure sores: Facility failed to provide timely repositioning for a resident with ongoing pressure ulcers, risking delayed healing and new sores.
F315 urinary catheter care: Facility failed to prevent urinary tract infections by improper catheter bag handling and failure to clean drainage spout for 2 residents with indwelling catheters.
F323 accident hazards: Facility failed to determine root causes of falls and develop effective interventions for 2 residents, risking additional falls.
F325 nutrition: Facility failed to ensure a resident received a planned nutritional supplement as ordered.
F329 unnecessary drugs: Facility failed to identify and monitor specific behaviors related to psychoactive medications for 3 residents, lacking targeted behavior monitoring and documentation.
F353 staffing: Facility failed to provide sufficient nursing staff to meet resident care needs and supervision, affecting all residents.
F364 food temperature and palatability: Facility failed to maintain proper holding temperatures for hot foods served to residents, risking food safety.
F371 food sanitation: Facility failed to ensure dietary staff wore proper hair and beard restraints and failed to properly clean food temperature probes, risking food contamination.
F428 drug regimen review: Pharmacist failed to identify lack of targeted behavior monitoring for psychoactive medications and failed to ensure effectiveness monitoring for 3 residents.
F431 drug records and storage: Facility failed to label opened medications with discard dates, failed to discard expired medications, and failed to store insulin pens per manufacturer recommendations.
F441 infection control: Facility failed to prevent infection spread by improper glove use during wound care and peri-care, and failed to follow disinfectant manufacturer instructions for cleaning resident rooms.
F520 quality assessment and assurance: Facility failed to maintain an effective QA committee that identified and corrected quality deficiencies related to resident care and quality of life.
Report Facts
Facility census: 72
Sample size: 23
Deficiency counts: 17
Weight: 140
Albumin level: 2.3
Food temperature: 108
Food temperature: 107
Food temperature: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff KK | Licensed Nursing Staff | Mentioned in dignified care and nail care findings |
| Staff B | Direct Care Staff | Mentioned in dignified care, catheter care, and wound care findings |
| Staff LL | Direct Care Staff | Mentioned in dignified care and nail care findings |
| Staff T | Direct Care Staff | Mentioned in dignified care and catheter care findings |
| Staff U | Direct Care Staff | Mentioned in dignified care and catheter care findings |
| Staff S | Direct Care Staff | Mentioned in catheter care and staffing findings |
| Staff Q | Direct Care Staff | Mentioned in catheter care and fall risk findings |
| Staff GG | Direct Care Staff | Mentioned in medication monitoring findings |
| Staff EE | Licensed Nursing Staff | Mentioned in medication monitoring and behavior monitoring |
| Staff FF | Licensed Nursing Staff | Mentioned in staffing and behavior monitoring |
| Staff NN | Licensed Nursing Staff | Mentioned in medication storage findings |
| Staff CC | Housekeeping Staff | Mentioned in infection control findings |
| Staff AA | Housekeeping Staff | Mentioned in infection control findings |
| Staff E | Dietary Staff | Mentioned in food temperature and hair restraint findings |
| Staff BB | Dietary Staff | Mentioned in facial hair restraint findings |
| Staff Y | Licensed Nursing Staff | Mentioned in medication monitoring and behavior monitoring |
| Staff P | Administrative Nursing Staff | Mentioned in care plan development and behavior monitoring |
| Staff A | Administrative Nursing Staff | Mentioned in QA committee and infection control findings |
| Staff N | Administrative Nursing Staff | Mentioned in fall prevention findings |
| Staff O | Administrative Nursing Staff | Mentioned in care plan development |
| Staff R | Activity Staff | Mentioned in nail care findings |
| Staff JJ | Licensed Nursing Staff | Mentioned in oral care observation |
| Staff W | Licensed Nursing Staff | Mentioned in catheter care and oral care findings |
| Staff V | Direct Care Staff | Mentioned in catheter care and sleep care findings |
| Staff LL | Direct Care Staff | Mentioned in sleep care and nail care findings |
| Staff T | Direct Care Staff | Mentioned in sleep care and catheter care findings |
| Staff KK | Licensed Nursing Staff | Mentioned in dignified care, nail care, and staffing findings |
| Staff UU | Licensed Nursing Staff | Mentioned in dignified care findings |
| Staff HH | Licensed Nursing Staff | Mentioned in housekeeping and medication storage findings |
| Staff II | Licensed Nursing Staff | Mentioned in housekeeping findings |
| Staff AA | Housekeeping Staff | Mentioned in housekeeping findings |
| Staff Z | Social Services Staff | Mentioned in dental services findings |
| Staff J | Therapist | Mentioned in care plan development |
| Staff GG | Direct Care Staff | Mentioned in medication monitoring |
| Staff DD | Direct Care Staff | Mentioned in medication monitoring |
| Staff QQ | Consultant Pharmacist | Mentioned in medication monitoring and pharmaceutical system findings |
Inspection Report
Follow-Up
Deficiencies: 5
Date: Sep 30, 2012
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
All deficiencies previously cited on the CMS-2567 have been corrected as of 09/30/2012, with corrections documented for multiple regulatory requirements.
Deficiencies (5)
Regulation 483.20(b)(1): Previously cited deficiency corrected as of 09/30/2012.
Regulations 483.20(d) and 483.20(k)(1): Previously cited deficiencies corrected as of 09/30/2012.
Regulation 483.25(e)(2): Previously cited deficiency corrected as of 09/30/2012.
Regulation 483.25(l): Previously cited deficiency corrected as of 09/30/2012.
Regulation 483.60(c): Previously cited deficiency corrected as of 09/30/2012.
Inspection Report
Follow-Up
Deficiencies: 5
Date: Sep 30, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as of the revisit date.
Findings
All deficiencies previously reported on the CMS-2567 were corrected by the revisit date of 09/30/2012, as documented by the correction completion dates.
Deficiencies (5)
Regulation 483.20(b)(1) deficiency was corrected by 09/30/2012.
Regulations 483.20(d) and 483.20(k)(1) deficiencies were corrected by 09/30/2012.
Regulation 483.25(e)(2) deficiency was corrected by 09/30/2012.
Regulation 483.25(l) deficiency was corrected by 09/30/2012.
Regulation 483.60(c) deficiency was corrected by 09/30/2012.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: Sep 30, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection. It outlines corrective actions to address identified issues related to resident care and compliance.
Findings
The plan addresses deficiencies including comprehensive resident assessments, care plan development, treatment of residents with limited range of motion, and ensuring drug regimens are free from unnecessary medications. The facility commits to audits and monitoring to ensure compliance.
Deficiencies (5)
F272-D: The facility will conduct comprehensive, accurate, standardized assessments of each resident's functional capacity, including oral health and discharge planning.
F279-D: The facility will use assessment results to develop, review, and revise comprehensive care plans tailored to residents' medical, nursing, mental, psychosocial, and nutritional needs.
F318-D: The facility will ensure residents with limited range of motion receive appropriate treatment and services to prevent further decline, including proper use of splints and documentation of refusals.
F329-D: The facility will ensure each resident's drug regimen is free from unnecessary drugs, with documentation and monitoring of blood sugar parameters for affected residents.
F428-D: The facility will ensure pharmacists report any irregularities to the attending physician and director of nursing, with follow-up actions taken accordingly.
Inspection Report
Re-Inspection
Census: 67
Deficiencies: 5
Date: Sep 7, 2012
Visit Reason
Health Resurvey and Complaint Investigations #56085, #57688, and #56668 were conducted to assess compliance with comprehensive assessments, care planning, range of motion treatment, drug regimen monitoring, and pharmacist reporting requirements.
Complaint Details
The inspection was triggered by complaint investigations #56085, #57688, and #56668.
Findings
The facility failed to conduct accurate comprehensive assessments for some residents, develop comprehensive care plans including coordination with hospice, ensure appropriate treatment to prevent decrease in range of motion, adequately monitor blood sugars for a diabetic resident, and ensure the pharmacist reported irregularities in medication monitoring.
Deficiencies (5)
F272: The facility failed to complete comprehensive assessments accurately, missing dental and discharge planning details for 2 of 25 sampled residents.
F279: The facility failed to develop comprehensive care plans for 2 of 28 sampled residents, lacking coordination with hospice and dental care interventions.
F318: The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion for 1 sampled resident.
F329: The facility failed to adequately monitor blood sugars and notify the physician for elevated levels in 1 sampled resident receiving insulin.
F428: The facility's pharmacist failed to report inadequate monitoring of elevated blood sugars to the director of nursing for 1 sampled resident.
Report Facts
Resident census: 67
Residents sampled: 28
Residents investigated for unnecessary medications: 10
Blood sugar readings above 350: 6
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N087063 POC MY8Z11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory finding for the facility identified by State ID N087063.
Findings
No deficiencies or findings are detailed in this document. It serves as a placeholder or record for the Plan of Correction submission.
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