Inspection Reports for
Three Peaks Assisted Living
2258 North 75 East, Cedar City, UT, 84721
Back to Facility ProfileDeficiencies (over last year)
Deficiencies (over last year)
32 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
305% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Routine
Deficiencies: 32
Date: Mar 11, 2025
Visit Reason
Unannounced routine inspection of Three Peaks Assisted Living to assess compliance with state assisted living facility regulations.
Findings
The inspection identified multiple compliance issues including missing identification badges for direct-care employees, incomplete training records, medication administration errors, missing infection control policies, inadequate emergency preparedness plans, unsecured hazardous materials, and deficiencies in resident assessments and service plans.
Deficiencies (32)
R432-1-4 Identification Badges: Direct-care employees were not wearing identification badges.
R432-270-9(10) The facility administrator did not complete the required annual dementia and Alzheimer's training timely.
R432-270-9(14) Three employees were not skin tested for tuberculosis within two weeks of hire and two employees lacked health inventory forms.
R432-270-9(15) No infection control policy was provided for review by the department.
R432-270-12(6)(a-c) One resident assessment did not include diagnosis on the initial assessment.
R432-270-13(3)(a-b) One resident assessment was not accurate at the time of assessment.
R432-270-14(2) Seven resident assessments were not used to develop their service plans.
R432-270-14(3)(e) Seven residents' service plans did not include the frequency of services and who would provide the service.
R432-270-15(1) No policy was provided defining the level of nursing services provided by the facility.
R432-270-16(2)(a-b) Two residents did not have wander risk or secure unit agreements.
R432-270-16(4) The CNA left the secure unit during the inspection.
R432-270-16(5) There was no emergency evacuation plan in the secure unit.
R432-270-18(7) One resident on a CCHO diet was not seen quarterly by a dietician.
R432-270-19(5)(a-b) One resident was not assessed to self-administer medications and had multiple medications at bedside.
R432-270-19(7)(a-f) One resident did not receive medications per physician orders.
R432-270-19(8) Two residents were assessed as independent with medication administration but were not able to independently administer medications.
R432-270-19(14) One resident did not have medications available and the health care professional was not notified of the medication error.
R432-270-19(15) No medication error incident report was completed for a medication error.
R432-270-20 Management of Resident Funds: The facility is not managing residents' funds according to regulations.
R432-270-21(2) Nurses station computer was unlocked with records not protected.
R432-270-21(3)(d-f) Four terminated employees did not have documentation for reason for leaving, first aid/CPR training, or TB tests.
R432-270-21(4)(b)(iii) Four residents' records did not contain the name of the dentist to be called in an emergency.
R432-270-21(6) The facility did not have incident reports for three resident deaths.
R432-270-23(6)(b) No training documentation regarding housekeeping processes was found for one employee.
R432-270-23(5) Cleaning agents and hazardous materials were stored unsecured in multiple locations.
R432-270-25(1) Maintenance issues included unsecured scissors, oxygen and carbon monoxide tanks, unlocked electrical panels, and fire doors with excessive gaps.
R432-270-26(4)(a-k) Emergency and disaster plans were missing multiple required disaster types including fire, severe weather, and mass casualty.
R432-270-26(6)(a-j) The emergency and disaster response plan did not include all required elements.
R432-270-26(8)(a-d) There was no documentation of fire and disaster drills.
R432-270-26(10)(a-g) Emergency supplies lacked extra blankets and a radio.
R432-270-26(11)(a-b) Emergency information was not posted in prominent locations throughout the facility.
R432-35-3(3) Four employees' current status was not reflected in DACS within five working days.
Report Facts
Number of rule noncompliances: 59
Employees missing documentation: 4
Residents missing dentist info: 4
Residents missing incident reports: 3
Residents missing service plan elements: 7
Residents missing assessments used in service plan: 7
Residents missing wander risk agreements: 2
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