Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WESTVIEW OF DERBY REHABILITATION & HEALTH CARE CEN
DERBY, KS · 78 certified beds · Last Life Safety survey March 5, 2025
CMS Certification Number 175218 · first certified April 1992
Ownership
Operated by TUTERA SENIOR LIVING & HEALTH CARE · For profit - Limited Liability company
- Ownership changed August 1, 2021 (change of ownership)to WESTVIEW OF DERBY REHABILITATION & HEALTH CARE CENTER LLC from LSL OF DERBY KS LLC
Position within KS
55 citations — more than 98% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 26 citations; the earlier surveys in the window averaged 14.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens October 2026 — about 1 month from now. This facility’s last Life Safety survey was March 2025. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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11 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
12 of the 55 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
10 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 55 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 55 |
| Median facility in KS | 27 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 30, 2021 | 8 |
| May 18, 2023 | 21 |
| March 5, 2025 | 26 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2025-03-05 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2025-03-05 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2025-03-05 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-03-05 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-03-05 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2025-03-05 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 2 | 2025-03-05 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 2 | 2025-03-05 |
What the citations cover
- Smoke Deficiencies 15
- Emergency Preparedness Deficiencies 12
- Gas, Vacuum, and Electrical Systems Deficiencies 10
- Egress Deficiencies 7
- Other 11
| Category | Citations |
|---|---|
| Smoke Deficiencies | 15 |
| Emergency Preparedness Deficiencies | 12 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 10 |
| Egress Deficiencies | 7 |
| Miscellaneous Deficiencies | 7 |
| Services Deficiencies | 3 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 5, 2025 — 26 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (June 3, 2025) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (June 3, 2025) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (June 3, 2025) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (June 3, 2025) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0100 | Meet other general requirements. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0222 | 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. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (April 15, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0924 | Ensure that anesthesia apparatus are tested after any adjustment, modification or repair. | Deficient, Provider has date of correction (June 3, 2025) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (June 3, 2025) |
May 18, 2023 — 21 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (August 1, 2023) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (August 1, 2023) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (August 1, 2023) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (August 1, 2023) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (August 1, 2023) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (August 1, 2023) |
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0222 | 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. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0500 | Meet other general requirements that are deficient. | Waiver has been granted (May 17, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (August 1, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (August 1, 2023) |
September 30, 2021 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Past Non-Compliance (September 30, 2021) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (November 12, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 12, 2021) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 12, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (November 12, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 12, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 12, 2021) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (November 12, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.