Draper Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at Draper Rehabilitation and Care Center, in the surveyor’s own words.

• Actual harm, isolatedF805Aug 25, 2026

  Based on interview and record review, the facility failed to ensure residents received a safe diet that met their special dietary needs for 1 out of 24 sampled residents. Specifically, Resident 1, who had a diet order for a minced and moist texture, was provided or obtained a muffin, which resulted in an airway obstruction. Resident identifier: 1Resident 1 was initially admitted to the facility on [DATE] with diagnoses including Parkinsonism, chronic obstructive pulmonary disease, dementia, acute kidney failure, and epilepsy. […]

• Actual harm, isolatedF686Nov 24, 2025

  Based on interview and record review, the facility did not provide care to prevent pressure ulcers. Specifically, for 1 out of 26 sampled residents, a resident developed a pressure ulcer from wearing an ankle foot orthosis (AFO) device. This resulted in a harm. Resident identifier: 7.Findings included: Resident 7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, essential tremor, difficulty in walking, generalized muscle weakness, and unsteadiness on feet.On 11/17/25 at 10:23 AM, an interview and observation was conducted with resident 7. Resident 7 stated that she had a wound on her left heel that she had for a very long time. […]

• No harm, potential for more than minimal, widespreadF812Nov 24, 2025

  Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were undated food items stored in the refrigerator, dry storage, and freezer, a beardnet was not worn by a dietary aide; resident refrigerators' had undated and opened juice and food, and the sanitizer bucket was not testing at the required sanitation levels.Findings included:1. On 11/17/25 at 8:36 AM, an initial tour of the kitchen was conducted. The following observations were made:a. A box of fudgesicles was opened and undated in the freezer.b. Two Boston Cream pies were undated in the freezer.c. A container of sugar free lemonade was not labeled and undated in the refrigerator.d. […]

• No harm, potential for more than minimal, patternF610Aug 5, 2026

  Based on interview and record review, the facility failed to ensure, for 2 of 7 sampled residents, that alleged violations involving residents were thoroughly investigated. Specifically, facility-reported incident investigations lacked complete information regarding interviews, protective measures, substantiated determinations, and systemic corrective actions. Resident Identifiers: 1 and 3. On 8/5/2026, the surveyor conducted a review of a facility reported incidents.The facility reported an incident involving Resident 1 on 7/7/2026. The facility failed to provide documentation of a 5 day follow-up investigation. The facility reported an incident involving Resident 1 on 7/1/2026. The facility's investigation stated, Follow up to [Resident 1]. […]

• No harm, potential for more than minimal, patternF605Nov 24, 2025

  Based on interview and record review, the facility did not ensure that residents who use psychotropic drugs received a gradual dose reduction (GDR), unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 4 out of 26 sampled residents, residents did not have an attempted GDR for psychotropic medications. Resident identifiers: 4, 9, 10, and 11.Findings included:1. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, cognitive communication deficit, dementia, generalized anxiety disorder, and mood disorder due to known physiological condition with depressive features. Resident 4's medical record was reviewed. […]