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DERBY HEALTH & REHABILITATION LLC

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DERBY HEALTH & REHABILITATION LLC VS
Nursing Homes USA
General
Percent of short-stay residents with Pressure ulcers that are new or worsened 2 % 
City Derby  0% Nursing Homes USA have Derby
State attribute explanation KS   2.2% Nursing Homes USA have KS
Street 731 KLEIN CIRCLE  
Zip Code 67037  
Phone 3167192400  
Overall Star Rating
3.11
Health Inspections Star Rating
2.83
Nurse Staffing Star Rating
3.17
Quality Measures Star Rating
3.31
RN Only Star Rating
3.17
Number of Certified Beds
74 
108.94
Total Number of Residents
69 
91.25
Percent of Occupied Beds
93 %
83.65 %
Health Survey Date 5/19/2011  
Fire Survey Date 11/10/2010  
Sprinkler Status Fully Sprinklered  90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Partnership  7.9% Nursing Homes USA have For profit - Partnership
Located Within a Hospital? No  93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? No  45.1% Nursing Homes USA don't have Multi Nursing Home Ownership?
Resident and Family Councils RESIDENT   66% Nursing Homes USA have RESIDENT
Continuing Care Retirement Community? No  90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? Yes  31.3% Nursing Homes USA have Quality Indicator Survey?
Special Focus Facility? No  99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
58.16
Total Enforcement Actions Count
56.31
# of deficiencies
42 
7.48
Staff Information
Number of Residents
69 
91.38
Number of RN Hours Per Resident Per Day
1.09 
0.77
Number of LPN/LVN Hours Per Resident Per Day
0.66 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.75 
1.59
Number of CNA Hours Per Resident Per Day
0.16 
5.49
Number Therapy Hours Per Resident Per Day
0.16 
0.10
Environmental Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Make Sure That A Working Call System Is Available In Each Resident's Room Or Bathroom And Bathing Area.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 06/17/2010
date Of Correction: 08/02/2010 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 05/04/2010
date Of Correction: 05/18/2010 
Deficiency #5 Scope: Many
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 02/09/2010
date Of Correction: 02/12/2010 
Mistreatment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: 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.
survey Date: 06/17/2010
date Of Correction: 08/02/2010 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: 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.
survey Date: 05/04/2010
date Of Correction: 05/12/2010 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: 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.
survey Date: 02/09/2010
date Of Correction: 02/12/2010 
Resident Rights Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Make Sure Each Resident Has The Right To Have A Choice Over Activities, Their Schedules And Health Care According To His Or Her Interests, Assessment, And Plan Of Care.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Notify The Resident Or Provide Reasons For A Transfer Or Discharge.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #4 Scope: Many
level Of Harm: 1
deficiency: Allow Residents To Easily View The Results Of The Nursing Home's Most Recent Survey.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #6 Scope: Many
level Of Harm: 1
deficiency: Give Each Resident A Notice Of Rights, Rules, Services And Charges. Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items And Services Medicaid Covers And Which The Resident Must Pay For.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #7 Scope: Few
level Of Harm: 2
deficiency: Provide Enough Notice Before Discharging Or Transferring A Resident.
survey Date: 09/09/2010
date Of Correction: 09/14/2010 
Deficiency #8 Scope: Few
level Of Harm: 2
deficiency: Let The Resident Or The Resident's Legal Representative The Right To Access Or Purchase Copies Of All Records.
survey Date: 06/17/2010
date Of Correction: 08/02/2010 
Quality Care Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Have Enough Nurses To Care For Every Resident In A Way That Maximizes The Resident's Well Being.
survey Date: 09/07/2011
date Of Correction: Not Available 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 07/19/2011
date Of Correction: Not Available 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Each Resident Who Enters The Nursing Home Without A Catheter Is Not Given A Catheter, And Receive Proper Services To Prevent Urinary Tract Infections And Restore Normal Bladder Function.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #6 Scope: Many
level Of Harm: 2
deficiency: Have Enough Nurses To Care For Every Resident In A Way That Maximizes The Resident's Well Being.
survey Date: 05/04/2010
date Of Correction: 05/14/2010 
Deficiency #7 Scope: Few
level Of Harm: 2
deficiency: Develop Policies And Procedures For Influenza And Pneumococcal Immunizations.
survey Date: 02/09/2010
date Of Correction: 02/12/2010 
Deficiency #8 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Each Resident Gets A Nutritional And Well Balanced Diet, Unless It Is Not Possible To Do So.
survey Date: 02/09/2010
date Of Correction: 02/12/2010 
Deficiency #9 Scope: Few
level Of Harm: 2
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 02/09/2010
date Of Correction: 02/12/2010 
Resident Assessment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.
survey Date: 06/17/2010
date Of Correction: 08/02/2010 
Deficiency #5 Scope: Some
level Of Harm: 2
deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.
survey Date: 02/09/2010
date Of Correction: 02/12/2010 
Administration Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 2
deficiency: Set Up An Ongoing Quality Assessment And Assurance Group To Review Quality Deficiencies Quarterly, And Develop Corrective Plans Of Action.
survey Date: 08/02/2010
date Of Correction: 08/30/2010 
Deficiency #2 Scope: Many
level Of Harm: 2
deficiency: Set Up An Ongoing Quality Assessment And Assurance Group To Review Quality Deficiencies Quarterly, And Develop Corrective Plans Of Action.
survey Date: 06/17/2010
date Of Correction: 08/30/2010 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 06/17/2010
date Of Correction: 08/02/2010 
Pharmacy Service Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.
survey Date: 07/19/2011
date Of Correction: Not Available 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Keep The Rate Of Medication Errors (wrong Drug, Wrong Dose, Wrong Time) To Less Than 5%.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #4 Scope: Some
level Of Harm: 2
deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.
survey Date: 02/09/2010
date Of Correction: 02/12/2010 
Deficiency #6 Scope: Some
level Of Harm: 2
deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.
survey Date: 02/09/2010
date Of Correction: 02/12/2010 
Nutrition and Dietary Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 2
deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.
survey Date: 05/19/2011
date Of Correction: 06/10/2011 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: 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.
survey Date: 08/02/2010
date Of Correction: 08/30/2010 
Deficiency #3 Scope: Many
level Of Harm: 2
deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.
survey Date: 02/09/2010
date Of Correction: 02/12/2010 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
13.2 %
25.09 %
Percent of long-stay residents whose need for help with daily activities has increased
2.5 %
32.95 %
Percent of long-stay residents who lose too much weight
2.9 %
11.83 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
3.3 %
15.63 %
Percent of long-stay residents with a urinary tract infection
11.4 %
13.46 %
Percent of long-stay residents who have depressive symptoms
14.3 %
28.38 %
Percent of long-stay residents who were physically restrained
75.2 %
43.68 %
Percent of short-stay residents who self-report moderate to severe pain
33 %
25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
91 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
89.3 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication
3 %
45.90 %
Percent of long-stay residents experiencing one or more falls with major injury
2.7 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
18.8 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
2 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain 18.2:1 % 
Percent of long-stay high-risk residents with pressure ulcers
2.7 %
9.22 %
Percent of long-stay residents who lose too much weight 5.6:1 % 
Percent of long-stay low-risk residents who lose control of their bowels or bladder
35.1 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
6.3 %
10.65 %
Percent of long-stay residents with a urinary tract infection 9.4 / 10.4 % 
Percent of long-stay residents who have depressive symptoms 17.1:1 % 
Percent of long-stay residents who were physically restrained
75.2 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
2.7 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
35 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
90.1 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
81.4 %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication
20.7 (69.3) %
17.34 %

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