Inspection Reports for The Ashford of Draper
14178 South Bangerter Parkway, Draper, UT, 84020
Back to Facility ProfileDeficiencies (last 1 years)
Deficiencies (over 1 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Census: 137
Capacity: 209
Deficiencies: 13
Date: Nov 20, 2024
Visit Reason
Routine inspection of an assisted living facility to assess compliance with state regulations including licensing, resident care, safety, and administrative requirements.
Findings
The facility was generally compliant with most regulations but had several deficiencies including incomplete hospice service plans, inaccurate resident assessments, incomplete service plans, unsecured scissors and cleaning supplies, missing emergency evacuation plans for secure units, incomplete fire and disaster drills, and personnel issues such as delayed fingerprinting and unauthorized direct patient access.
Deficiencies (13)
6 residents did not have hospice services part of the resident's service plan and 3 hospice residents lacked a developed emergency evacuation plan.
1 resident assessment was not accurate at the time of assessment.
1 resident had a significant change with no significant change assessment completed.
10 resident assessments were not used to develop, review, and revise the service plan.
10 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 to potentially dangerous items.
Anti-fungal powder was stored in an unlocked closet in the memory care unit.
Resident records were accessible in an office that was not locked and left unattended.
Facility did not have a 30-day discharge notice served in the prior six months.
No fire drills for AM shift 1st quarter 2024, PM shift 2nd quarter 2024, PM or NOC shift 3rd quarter 2024, AM, PM, and NOC shift 4th quarter 2023. Drills did not include resident participants or ability to evacuate. Only 1 disaster drill in previous 12 months.
Emergency and disaster response plan lacked names of persons in charge, notification lists, emergency contacts, and assignment of personnel to specific tasks during emergencies.
Fingerprints for 1 employee were not completed within 15 working days of engagement.
1 employee continued to work with direct patient access after being determined not eligible for direct patient access by the department.
Report Facts
Residents present: 137
Total licensed capacity: 209
Deficiencies noted: 15
Compliant rules: 137
Not assessed rules: 52
Corrected during inspection: 10
Citation count: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| One employee had fingerprints not completed within 15 working days of engagement | ||
| One employee continued to work with direct patient access after being determined not eligible |
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