Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Derby Health & Rehabilitation, Llc during CMS and state inspections, most recent first.
Surveyors found that the facility did not provide required written notifications of transfer or notify the LTCO when three residents were transferred to the hospital, including one who later returned and two who did not. Staff reported that they notified representatives of hospital transfers by phone and documented progress notes, but did not complete written transfer notices and were unfamiliar with this requirement. Review of LTCO discharge notification emails over a one-year period showed that these hospital transfers were not reported. The facility’s policy required written notice with reasons, effective date, receiving location, LTCO and State Agency contacts, and appeal rights, but did not specifically address written notification or LTCO reporting for hospital transfers.
A resident with hypotension and intact cognition was started on an antihypotensive medication, with care plan directions to monitor blood pressure and pulse and to assess for side effects and effectiveness. After the resident reported low blood pressure and symptoms of dizziness and lightheadedness, a provider ordered orthostatic blood pressures twice daily for three days, including lying, sitting, and standing measurements, with results to be sent via EMR message. The EMAR showed that on multiple days only single blood pressure readings were documented, required orthostatic positions were missing, and some ordered evening orthostatic sets were not recorded at all, with one complete set documented only in a nurse’s note due to EMR entry issues. Staff interviews confirmed that CNAs usually obtained vitals, nurses later entered them, orthostatic technique varied, and required EMR messages with results could not be located, and no policy on orthostatic blood pressures was provided.
Staff failed to maintain hands-on stabilization of two residents during full body mechanical lift transfers, leaving them unsupported while the lift was in operation. In both cases, one staff member released physical contact to perform other tasks, contrary to facility expectations that require continuous hands-on support for resident safety. The facility's policy did not provide clear instructions on maintaining resident contact or proper lift positioning.
The facility failed to ensure hazardous chemicals were stored safely, placing five cognitively impaired and independently mobile residents at risk for injury. An unlocked housekeeping closet was found containing hazardous items such as fiberglass resin, tile sealer, ant killer, and ant and roach killer, all stored on a waist-high shelf. Staff confirmed that housekeeping closets should be locked when not supervised.
The facility failed to store, prepare, and serve food in a sanitary manner, with undated and improperly stored food items, and staff not adhering to hand hygiene protocols. Observations revealed unclean kitchen equipment and non-compliance with the facility's cleaning schedule, placing residents at risk for food-borne illness.
The facility failed to provide three residents with the correct CMS Skilled Nursing Facility Advanced Beneficiary Notices (ABN) Form 10055, instead giving them the CMS-R-131 form. This error prevented the residents from making informed decisions about their skilled services and potential financial liabilities.
The facility failed to protect residents from abuse when multiple residents' controlled medications were misappropriated. An LN received and signed for the medications, which later went missing. Despite a search and investigation, the medications and narcotic count sheets were not found, affecting three residents and placing them at risk for further abuse and impaired care.
The facility failed to provide proper G-tube care for a resident with multiple medical conditions by not administering the required 45 ml water flush before a nutritional feeding, as per the physician's orders. This lapse was confirmed by a consultant and was contrary to the facility's Enteral Nutrition policy, placing the resident at risk for complications.
The facility failed to ensure a Consultant Pharmacist identified and reported a resident's blood pressure medication administered outside physician-ordered parameters, placing the resident at risk for unnecessary medications and related complications. Despite multiple instances of incorrect administration, the pharmacist's review did not note these irregularities, and the physician was not notified.
The facility failed to follow physician-ordered parameters for administering midodrine to a resident, resulting in the administration of the medication multiple times when the resident's systolic blood pressure exceeded the specified threshold. This failure placed the resident at risk for unnecessary medications and related complications.
Failure to Provide Written Transfer Notices and LTCO Notification for Hospital Transfers
Penalty
Summary
Surveyors identified that the facility failed to provide required written notifications of transfer for three residents who experienced facility-initiated transfers to the hospital, and also failed to notify the State Long Term Care Ombudsman (LTCO) of these transfers/discharges. The census was 61 residents, with a sample of 15, including three residents reviewed for hospitalization. One resident was admitted to the facility, transferred to the hospital, and later readmitted, while two other residents were admitted, transferred to the hospital, and did not return. When surveyors requested documentation, the facility was unable to provide written notifications of transfer for any of these hospital transfers. Review of LTCO notification emails for discharges over a one-year period showed that these hospital transfers were not included. During observations and interviews, one of the residents was seen sitting in a wheelchair at a dining room table eating breakfast. A consultant stated that the facility did not do written notifications of transfers. A licensed nurse reported that when a resident transferred to the hospital, she notified the resident’s representative by phone but did not complete a written notification of transfer. The social services staff member stated that she called families about bed holds and documented a progress note but did not complete written notifications of transfer and did not know what they were. She also stated she completed ombudsman reports on discharges, including hospital transfers, but that residents were only included if they were discharged after hospital admission, and she usually reviewed the list to ensure hospital transfers were included. The facility’s Admission, Transfer, and Discharge Policy required a 30-day advanced written notice, except in emergencies, including the reason for transfer/discharge, effective date, receiving location, LTCO contact, State Agency contact, and appeal rights, but the policy did not address written notification of hospital transfers or LTCO notification of transfers.
Failure to Complete and Document Ordered Orthostatic Blood Pressures
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document physician-ordered orthostatic blood pressures for a resident being evaluated for dizziness and lightheadedness. The resident had diagnoses of anxiety and hypotension and an admission MDS BIMS score of 14, indicating intact cognition. The care plan documented use of an antihypotensive medication for hypotension, with directions to monitor and document side effects and effectiveness, and to verify blood pressure and pulse prior to administering the medication. Following a progress note documenting low blood pressure and the resident’s report that their blood pressure had always been low, the provider ordered orthostatic blood pressures twice daily for three days, with lying, sitting, and standing measurements and instructions to send the results via EMR message. The EMR contained the order starting on 02/28/26. Despite this order, the EMAR showed incomplete and missing orthostatic blood pressure documentation. On 02/28/26, only a single blood pressure reading was recorded without the required lying, sitting, and standing values, and there was no documentation for the evening orthostatic set. On 03/01/26, the morning orthostatic entry was marked as not applicable, and the evening entry required reference to a nurse’s note because the system would not allow entry of the readings in the designated fields; the nurse’s note documented all three positions. On 03/02/26, again only a single blood pressure reading was recorded, with no orthostatic breakdown, and no evening orthostatic documentation. Staff interviews revealed that CNAs typically obtained vital signs and nurses later entered them into the computer, that one CMA only checked vitals before certain heart medications and not for this resident, and that one nurse preferred to perform orthostatic measurements herself due to concerns about CNAs’ technique. The administrative nurse stated that orthostatic results should be entered into the EMR and messaged to the provider, but staff were unable to locate these messages. No policy regarding orthostatic blood pressures was provided.
Failure to Maintain Resident Safety During Mechanical Lift Transfers
Penalty
Summary
Staff failed to ensure an environment free from accident hazards during full body mechanical lift transfers for two residents. In both observed incidents, one staff member operated the lift controls while the second staff member, who was responsible for maintaining hands-on stabilization of the resident, released physical contact and attended to other tasks. Specifically, during a transfer from a recliner to a wheelchair, the second staff member let go of the resident to walk around the lift and stand behind the wheelchair, leaving the resident in a raised and unsupported position. In another instance, during a transfer from a wheelchair to a bed, the second staff member let go of the resident to open a bathroom door and move the wheelchair, again leaving the resident unsupported while the lift was in operation. Interviews with the involved staff confirmed that they would not have performed the lift tasks differently and acknowledged releasing physical control of the residents during the transfers. Licensed nursing staff and administrative personnel stated that proper procedure requires two staff members: one to operate the lift and the other to maintain hands-on contact with the resident at all times for safety. Additionally, the facility's mechanical lift policy lacked specific guidance on maintaining resident contact and proper positioning of the lift legs during transfers.
Unsafe Storage of Hazardous Chemicals
Penalty
Summary
The facility failed to ensure hazardous chemicals were stored safely, placing five cognitively impaired and independently mobile residents at risk for injury. During an observation in the 300-household area, an unlocked housekeeping closet was found containing hazardous items such as fiberglass resin, tile sealer, ant killer, and ant and roach killer, all stored on a waist-high shelf. These items had instructions to keep out of reach of children. A Certified Nurse Aide verified the findings, and an Administrative Nurse confirmed that staff should ensure housekeeping closets are locked when not supervised. The facility's Chemical Storage policy stated that all hazardous chemicals should be stored in a locked area or used under supervision.
Failure to Maintain Sanitary Food Storage and Service Practices
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner for residents in two of four kitchens and dining rooms. Observations revealed undated and improperly stored food items in the 100-household kitchen freezer, including a bag of chicken tenders and a box of hamburger patties with a torn plastic bag. Additionally, Certified Nurse Aide (CNA) M was observed serving food to residents without washing or sanitizing his hands after touching his face, hair, and clothing, which occurred in both the 300-household dining room and the 200-household dining room. The facility's cleaning schedule was not adhered to, as evidenced by dried crumbs on toasters and dried food spills on oven doors in the 100 and 300 household kitchens, despite staff initialing the cleaning schedule as completed for certain tasks. Dietary Staff BB confirmed the findings of undated and improperly stored food items, as well as the unclean state of the ovens and toasters. The facility's policies on food preparation, sanitation, and food storage were not followed, as staff failed to perform hand hygiene after touching their face, hair, or clothing, and did not properly label or cover food items. These deficiencies placed residents at risk for food-borne illness due to the lack of adherence to professional standards for food storage, preparation, and service.
Failure to Provide Correct Medicare ABN Form
Penalty
Summary
The facility failed to provide three residents, or their representatives, with the correct Centers for Medicare and Medicaid (CMS) Skilled Nursing Facility Advanced Beneficiary Notices (ABN) Form 10055. Instead, the residents received the CMS-R-131 form, which is not the appropriate form for informing beneficiaries about potential non-coverage of future skilled therapy services. This error was identified through a review of the records for residents R8, R11, and R160, whose skilled services ended on different dates. The incorrect form did not provide the necessary information for the residents to make informed decisions about their skilled services and potential financial liabilities. Interviews with facility staff, including Social Services and a consultant, confirmed that the CMS-R-131 form was mistakenly provided to the residents instead of the required Form 10055. The facility's policy on Medicare Denial Notices, dated March 13, 2024, mandates that residents be informed about services not covered under Medicare and provided with the correct ABN form to decide whether to appeal a decision to terminate Medicare care and services. The failure to provide the correct form placed the residents at risk of making uninformed decisions regarding their skilled services and financial responsibilities.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to ensure residents remained free from abuse when multiple residents' medications were misappropriated. The incident involved the disappearance of three narcotic cards containing controlled medications, including oxycodone and hydrocodone-acetaminophen, which were delivered to the facility and signed for by a Licensed Nurse (LN). The medications were intended for three residents, and the loss was discovered when an Administrative Nurse noted that one resident's entire card of oxycodone was missing. Despite a thorough search of the medication carts and the shred box, the medications and narcotic count sheets could not be located. The LN responsible for receiving the medications was contacted and initially stated she might have accidentally placed them in the shred box, but no evidence was found to support this claim. The LN later provided a witness statement and a urine sample after returning to the facility from out of town. The facility's investigation revealed that the misappropriation affected three residents, with a total of 62 tablets of controlled medications missing. The facility contacted the police department and gathered statements from staff members. Observations of the medication carts in various houses within the facility confirmed that narcotic medications were stored in locked metal boxes affixed to the carts, which were also locked when not in use. The facility's policy on Abuse, Neglect, and Exploitation emphasized the prohibition of mistreatment, neglect, and abuse of residents, including the misappropriation of elder property. However, the facility failed to adhere to this policy, resulting in the misappropriation of medications and placing residents at risk for further abuse and impaired care related to missing or stolen medications.
Failure to Administer Required Water Flushes for G-Tube Feeding
Penalty
Summary
The facility failed to provide proper G-tube care for Resident 41, who had a diagnosis of dysphasia, cerebrovascular accident, hemiplegia, and diabetes mellitus. The resident's care plan required the administration of Jevity 1.5 nutritional liquid through the G-tube four times a day, with 45 ml water flushes before and after each feeding. However, on the observed date, a licensed nurse administered the Jevity without the required 45 ml water flush prior to the feeding, contrary to the physician's orders. This failure was confirmed by a consultant who verified that the water flushes should have been administered as per the physician's order. The facility's Enteral Nutrition policy, dated 02/07/2022, outlined the procedure for administering enteral feedings, including the necessity of water flushes to meet hydration needs. Despite this policy, the staff did not follow the prescribed protocol, placing Resident 41 at risk for G-tube related complications. The deficiency was identified through observation, record review, and interviews, highlighting a significant lapse in adhering to the physician's orders and the facility's own policies for enteral nutrition management.
Failure to Identify and Report Medication Administration Errors
Penalty
Summary
The facility failed to ensure the Consultant Pharmacist identified and reported a resident's blood pressure medication administered outside the physician-ordered parameters. The resident, who had diagnoses including end-stage renal disease, atrial fibrillation, and hypocalcemia, was prescribed midodrine with specific instructions to hold the medication if the systolic blood pressure (SBP) was greater than 130. Despite this, the resident's Electronic Medical Record (EMR) documented multiple instances where midodrine was administered even when the SBP exceeded the ordered parameters. The Consultant Pharmacist's review did not note these irregularities, and there was no evidence that the physician was notified of the medication administration errors. This oversight placed the resident at risk for unnecessary medications and related complications. Observations and interviews confirmed that staff were aware of the requirement to hold midodrine if the SBP was greater than 130 but failed to do so on numerous occasions. The Consultant Pharmacist's report for the review period did not address the administration of midodrine outside the ordered parameters, and the facility's policy required the pharmacist to communicate potential or actual problems related to medication therapy to the responsible physician and the director of nursing. The failure to identify and report these medication errors was verified by administrative nurses, highlighting a significant lapse in the facility's medication management and review processes.
Failure to Follow Physician-Ordered Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to adhere to physician-ordered parameters for administering midodrine, a blood pressure medication, to Resident 47. Despite the physician's order to hold the medication if the systolic blood pressure (SBP) was greater than 130 mm/Hg, the medication was administered multiple times when the resident's SBP exceeded this threshold. Specific instances of this failure were documented in the resident's Electronic Medical Record (EMR), with blood pressure readings ranging from 132/83 mm/Hg to 172/119 mm/Hg on various dates. The Certified Medication Aide (CMA) and Administrative Nurse confirmed that the medication should have been held according to the physician's parameters, but it was not, leading to the administration of unnecessary drugs to the resident. Resident 47 had a history of end-stage renal disease, atrial fibrillation, and hypocalcemia, and was receiving high-risk medications, including antianxiety and opioid medications. The resident's care plan required one or two-person assistance for activities of daily living and documented that the resident received hemodialysis three times a week. Despite these detailed care instructions, the facility's failure to follow the physician's order for midodrine administration placed the resident at risk for unnecessary medications and related complications. The facility's Medication Administration policy required staff to document and follow holding or notification parameters for ordered medications, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Derby
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westview Of Derby Rehabilitation & Health Care Cen | 1.4 mi | ★★★★★ | 2 | 0 |
| Villa Maria | 5 mi | ★★★★★ | 0 | 0 |
| Advena Living At Fountainview | 5.8 mi | ★★★★★ | 0 | 0 |
| Diversicare Of Haysville | 6.5 mi | ★★★★★ | 0 | 0 |
| Caritas Center, Inc | 7.7 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.