Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Draper Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident with hemiplegia, weakness, and unsteady gait developed a left heel pressure injury after wearing an AFO. Nursing documented swelling, indentation, and later a fluid-filled blister that was thought to have come from the brace, and the wound progressed from a stage 2 pressure ulcer to an unstageable injury and then a stage 3 pressure injury. The wound nurse stated the injury was caused by the AFO and was avoidable, while the DON and DOR stated the brace should only be used for weight-bearing or transfers and was not needed while the resident sat in the wheelchair.
Food was not stored, prepared, distributed, and served in accordance with professional standards. Surveyors observed undated and unlabeled items in the kitchen refrigerator and freezer, as well as opened and undated food and beverages in a resident fridge. A sanitizer bucket tested at no chemical level before being corrected, and a dietary aide with a beard was observed without a beard net. Staff also observed glove use during tray line work that did not follow proper hand hygiene and glove-changing expectations.
Failure to Attempt GDR for Psychotropic Medications: The DON and record review showed that several residents receiving psychotropic meds, including antianxiety, antidepressant, mood stabilizer, and sleep medications, did not have documented GDR attempts or contraindication rationale. Behavior monitoring and MAR review showed little or no current target behaviors for the residents reviewed, yet the chart lacked evidence of GDRs for meds such as Ativan, duloxetine, Lamictal, trazodone, valproic acid, and temazepam.
Resident 6, who had dysphagia, malnutrition, and gastrostomy status, was repeatedly observed lying flat while enteral feedings were running, despite care plan and MD orders requiring the HOB to be elevated during and after feeding. The resident had an occasional wet cough during observations, and the DON stated the resident slid down in bed and needed frequent repositioning and suctioning. An LPN said the resident's mother placed pillows around the resident, which affected positioning.
Failure to Prevent AFO-Related Heel Pressure Injury
Penalty
Summary
A resident with hemiplegia and hemiparesis following cerebral infarction, essential tremor, difficulty walking, generalized muscle weakness, and unsteadiness on feet developed a left heel pressure ulcer after wearing an ankle foot orthosis (AFO) device. The resident was admitted to the facility and later readmitted, and the record shows the AFO had been identified as needing refitting or replacement. On 1/7/25, nursing documented swelling and indentation from the brace and educated staff to remove it while the resident was at rest and at bedtime after transfer into bed. On 2/21/25, nursing documented new right buttock, sacral, and left heel wounds, and the resident was instructed not to wear the AFO for now. On 2/25/25, the left heel was documented as a clear fluid-filled blister that may have come from wearing the AFO. Subsequent wound notes described the heel wound as a stage 2 pressure ulcer acquired on 2/27/25, later progressing to an unstageable pressure injury with no change in progression, then worsening with blood in the blister and later deterioration of the eschar. Interviews confirmed the wound was associated with the AFO. The wound nurse stated the pressure ulcer started as a blood blister, the facility tried to keep it from bursting, and the resident got the pressure ulcer from wearing the AFO device; the wound nurse also stated it was avoidable. The DON stated therapy managed braces and that nursing staff should monitor the site because they put the device on and off the resident. The DOR stated the AFO should only be worn during weight-bearing or transferring for joint stability and was not needed while the resident sat in the wheelchair, yet the resident had been wearing it in the morning and removed at night.
Food Storage, Labeling, and Sanitizer Practices Not Followed
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an initial kitchen tour, surveyors observed multiple undated or unlabeled food items in the freezer and refrigerator, including opened fudgesicles, Boston cream pies, sugar free lemonade, juice, and hardboiled eggs. The Dietary Manager stated that everything in the refrigerator, freezer, and dry storage should have a date of when it was received and when it was opened. The sanitizer bucket was also observed to be at an improper level when tested; the strip stayed orange, indicating no chemical was measured, and the Dietary Manager stated he had believed it had been changed earlier that morning.
Failure to Attempt GDR for Psychotropic Medications
Penalty
Summary
The facility did not ensure that residents receiving psychotropic medications had a gradual dose reduction (GDR) attempted unless clinically contraindicated. For 4 of 26 sampled residents, there was no documentation that a GDR had been attempted or that a dose reduction was contraindicated for the psychotropic medications reviewed. The deficiency involved residents 4, 9, 10, and 11, each of whom had ongoing psychotropic medication orders and behavior-monitoring documentation that did not show current behaviors supporting continued use in the record reviewed. Resident 4 had diagnoses including dementia, generalized anxiety disorder, and mood disorder with depressive features. The record showed orders for valproic acid for mood and temazepam for insomnia, along with behavior monitoring for angry outbursts and sleep. The November 2025 MAR showed no documented behaviors and an average of six hours of sleep at night. The Psychotropic Medication Review Form stated GDR was not indicated due to ongoing depressive and agitated behaviors, but it did not identify which medications were excluded from GDR. No documentation was found showing a GDR attempt for valproic acid or temazepam since 2024, or a physician rationale that GDR was clinically contraindicated. During interview, the DON stated the resident did not sleep and had aggressive behaviors, which was why GDR had not been done. Resident 11 had diagnoses including dementia, schizophrenia, anxiety disorder, obsessive compulsive disorder, major depressive disorder, and cognitive communication deficit. The record showed orders for Lamictal, Cymbalta, and trazodone, with monitoring for depression, crying/tearfulness, and angry outbursts. The November 2025 MAR showed no documented behaviors and an average of seven hours of sleep at night. No documentation was found showing a GDR attempt for Lamictal, Cymbalta, or trazodone since the medications were started, or that dose reduction was contraindicated. The DON stated the resident had required medication increases to become stable, that prior reduction of Seroquel had led to behaviors, that Depakote had been too sedating, and that the resident’s husband did not want medications decreased without his permission. Resident 10 had diagnoses including dementia, anxiety disorder due to known physiological condition, major depressive disorder, cognitive communication deficit, and altered mental status. The record showed duloxetine ordered for depression, with monitoring for depression and psychotic behavior. The November 2025 MAR showed no documented behaviors. No documentation was found showing a GDR attempt for duloxetine since 2023, or that dose reduction was contraindicated. The DON stated the team reviewed psychotropic medications at meetings and had been trying to decrease higher-risk medications first, with duloxetine also described as part of the resident’s chronic pain treatment. Resident 9 had diagnoses including major depressive disorder, anxiety disorder, and PTSD, and had an order for Ativan 0.5 mg twice daily for anxiety. Behavior monitoring showed no complaints of anxiety or extreme restlessness in September and November 2025, and only limited anxiety-related symptoms in October 2025. Psychotropic medication review forms repeatedly recommended maintaining the dose or reviewing again later, but no documentation was found showing a GDR attempt for Ativan since 2022 or that dose reduction was contraindicated. The DON stated the Ativan had been decreased from four times daily to twice daily years earlier, but no additional GDR had been attempted and no contraindication documentation could be found.
Resident Was Observed Flat During Tube Feeding
Penalty
Summary
The facility did not ensure that a resident receiving enteral nutrition was provided appropriate care to prevent complications of tube feeding. Resident 6 was admitted and readmitted with diagnoses including protein calorie malnutrition, profound intellectual disabilities, dysphagia, and gastrostomy status. The care plan directed that the head of the bed be elevated 45 degrees during tube feeding and at least 30 to 45 degrees at all times during feeding, and a physician order required the head of the bed to be elevated at least 30 degrees during feeding and for one hour afterward. During multiple observations, Resident 6 was seen lying flat in bed while tube feeding was running. On one observation, the resident had an occasional wet cough while a bag of Nutren 2.0 was infusing at 60 ml/hr and free water was infusing at 75 ml/hr. Additional observations on later dates again showed the resident positioned on the left side or flat in bed with tube feeding running and an occasional wet cough. The DON stated the resident was wiggly in bed and slid down, and that pillows under the resident's left side were propping the belly up so it was even with the chest. The DON also stated the resident always had a wet cough because he was unable to swallow secretions and needed suctioning all the time. An LPN stated the resident's mother was very particular about positioning and pillows, and that staff had to constantly reposition the resident.
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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 Draper
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Neurorestorative | 4.4 mi | ★★★★★ | 0 | 0 |
| Stonehenge Of South Jordan | 4.6 mi | ★★★★★ | 0 | 0 |
| Sandy Health And Rehab | 4.9 mi | ★★★★★ | 0 | 0 |
| Rocky Mountain Care - Riverton | 5.8 mi | ★★★★★ | 0 | 0 |
| Pointe Meadows Health And Rehabilitation | 6.6 mi | ★★★★★ | 0 | 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.