Derby Health & Rehabilitation, LLC
731 Klein Circle, Derby, KS 67037
Derby Health & Rehabilitation, LLC is a nursing home in Derby, Kansas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating5 of 5
- Last standard health inspectionMarch 11, 2026 (8 months ago)
- Health citations since November 8, 202214 (Kansas average 28)
- Fines in the past three yearsNone listed by CMS
- CMS flagsNone listed by CMS
Get an email when CMS publishes something new about this home
One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
Email alerts for this home open soon.
CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of May 27, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5.
Health inspection on March 11, 2026
2 citationsCMS lists this as a standard inspection.
Show the 2 citations
Citation F0628. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
CMS lists it as corrected on April 11, 2026.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 11, 2026.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
CMS update of July 30, 2025
Star rating
The CMS health inspection star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Health inspection on April 29, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 5, 2025.
CMS has cited this home for F0689 3 times since 2022.
CMS update of May 29, 2024
Ownership
CMS no longer lists a chain for this home.
Health inspection on April 30, 2024
7 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 7 citations
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 5, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 5, 2024.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on June 5, 2024.
Citation F0602. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from the wrongful use of the resident's belongings or money.
CMS lists it as corrected on June 5, 2024.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS lists it as corrected on June 5, 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on June 5, 2024.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on June 5, 2024.
Fire safety inspection on April 30, 2024
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation K0222. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
CMS lists it as corrected on June 21, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 21, 2024.
Citation K0355. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on June 24, 2024.
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on June 21, 2024.
CMS has cited this home for K0363 3 times since 2021.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on June 21, 2024.
CMS has cited this home for K0511 2 times since 2022.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on June 21, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on June 21, 2024.
CMS update of April 25, 2024
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Health inspection on November 8, 2022
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on November 18, 2022.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on November 18, 2022.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
CMS lists it as corrected on November 18, 2022.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on November 18, 2022.
Fire safety inspection on November 8, 2022
5 citationsCMS lists this as a standard inspection.
Show the 5 citations
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on January 5, 2023.
CMS has cited this home for K0324 2 times since 2021.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on January 5, 2023.
CMS has cited this home for K0345 2 times since 2021.
Citation K0920. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on January 5, 2023.
CMS has cited this home for K0920 2 times since 2021.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on January 5, 2023.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on January 5, 2023.
Fire safety inspection on May 12, 2021
9 citationsCMS lists this as a standard inspection.
Show the 9 citations
Citation E0007. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address patient/client population and determine types of services needed.
CMS lists it as corrected on June 20, 2021.
Citation E0015. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address subsistence needs for staff and patients.
CMS lists it as corrected on June 20, 2021.
Citation E0030. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
List the names and contact information of those in the facility.
CMS lists it as corrected on June 20, 2021.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on June 20, 2021.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on June 20, 2021.
Citation K0363. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on June 20, 2021.
Citation K0372. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on June 20, 2021.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on June 20, 2021.
Citation K0920. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on June 20, 2021.
CMS star ratings
- 5 of 5CMS overall star rating
- 5 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (316) 719-2400
- Last standard health inspection
- March 11, 2026 (8 months ago)
- Certified beds
- 74
- Residents per day, on average
- 71
- Ownership type
- For profit - Corporation
- Legal business name
- Derby Health & Rehabilitation
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Kansas average (14 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- AXIOM HEALTHCARE ALLIANCE, LLC5% or greater direct ownership interest · 100% · since 09/01/2020
- AXIOM CONSULTING LLC5% or greater indirect ownership interest · 9% · since 07/07/2015
- DENNIS L. ROSS POD TO TRUSTEE OF DENNIS L. ROSS LIVING TRUST U/A 4/4/15% or greater indirect ownership interest · 5% · since 09/01/2020
- MATT LILLIE INVESTMENTS, INC5% or greater indirect ownership interest · 8% · since 09/01/2020
- ROGER EVANS REVOCABLE TRUST5% or greater indirect ownership interest · 6% · since 09/01/2020
Show 8 more
- WICHITA WELLNESS INC5% or greater indirect ownership interest · 11% · since 09/01/2020
- EVANS, ROGER5% or greater indirect ownership interest · 6% · since 09/01/2020
- HERMES, FREDERICK5% or greater indirect ownership interest · 9% · since 09/01/2020
- LAKIN, GREGORY5% or greater indirect ownership interest · 11% · since 09/01/2020
- LILLIE, MATTHEW5% or greater indirect ownership interest · 8% · since 09/01/2020
- ROSS, ANN5% or greater indirect ownership interest · 5% · since 09/01/2020
- ROSS, DENNIS5% or greater indirect ownership interest · 5% · since 09/01/2020
- AXIOM HEALTHCARE SERVICES LLCOperational/managerial control · not applicable · since 10/23/2009
Questions
When was Derby Health & Rehabilitation, LLC last inspected?
CMS lists March 11, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Derby Health & Rehabilitation, LLC have?
CMS lists 14 health citations since November 8, 2022. CMS also calls these deficiencies.
Has Derby Health & Rehabilitation, LLC been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Derby Health & Rehabilitation, LLC?
Its CMS overall star rating is 5 of 5.
Is Derby Health & Rehabilitation, LLC a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.