Inspection Reports for
The Ashford of Draper
14178 South Bangerter Parkway, Draper, UT, 84020
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
90% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 15
Date: Nov 20, 2024
Visit Reason
Routine inspection of an assisted living facility to assess compliance with state licensing rules and regulations.
Findings
The inspection found multiple areas of noncompliance including deficiencies in resident assessments, service plans, medication administration, emergency preparedness, and staff training. Several safety and procedural issues were noted, such as unsecured hazardous items and incomplete emergency plans.
Deficiencies (15)
There were 6 residents without hospice services included in their service plans and 3 hospice residents lacked developed emergency evacuation plans.
Facility did not have a 30 day discharge notice served in the prior six months.
One resident assessment was not accurate at the time of assessment.
One resident had a significant change without a completed significant change assessment.
Ten resident assessments were not used to develop, review, or revise the service plan.
Ten resident service plans did not include how services are provided or the frequency of services.
Scissors were not locked in the facility, allowing unauthorized access.
Anti fungal powder was stored in an unlocked closet in the memory care unit.
Facility does not manage resident funds.
Resident records were accessible in an office that was not locked and left unattended.
Did not have the names of the person in charge and persons with decision-making authority, emergency contact names and numbers, or assignment of personnel to specific emergency tasks.
No fire drills conducted for AM shift 1st quarter 2024, PM shift 2nd quarter 2024, PM or night shift 3rd quarter 2024, and all shifts 4th quarter 2023. Drills did not include resident participation or evacuation ability. Only one disaster drill in previous 12 months.
No emergency evacuation plan for the secure unit.
Fingerprints for one employee were not completed within 15 working days of engagement.
One employee continued to work with direct patient access after being determined not eligible by the department.
Report Facts
Residents without hospice service plan: 6
Hospice residents without emergency evacuation plan: 3
Resident assessments inaccurate: 1
Resident assessments missing significant change assessment: 1
Resident assessments not used for service plan: 10
Resident service plans missing details: 10
Fire drills missing: 4
Disaster drills in last 12 months: 1
Fingerprint delay: 1
Unauthorized employee with direct patient access: 1
Loading inspection reports...
