Inspection Reports for Three Peaks Assisted Living
2258 North 75 East, Cedar City, UT, 84721
Back to Facility ProfileDeficiencies (last 1 years)
Deficiencies (over 1 years)
31 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
292% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
32
24
16
8
0
Inspection Report
Routine
Deficiencies: 31
Date: Mar 11, 2025
Visit Reason
The inspection was an unannounced routine inspection conducted to review compliance with assisted living facility regulations.
Findings
The inspection identified multiple rule noncompliances across various regulatory areas including personnel records, medication administration, resident assessments, service plans, emergency preparedness, maintenance, and resident funds management. Several deficiencies were noted with some corrected during the inspection and others requiring follow-up.
Deficiencies (31)
Direct-care employees were not wearing identification badges.
4 hours of administrator training were from January and February of 2023, not current.
3 employees were not skin tested for TB within 2 weeks of hire; 2 employees did not have health inventory forms in file.
No infection control policy provided for review by the department.
1 resident assessment did not include diagnosis on initial assessment.
7 resident assessments were not used to develop their service plans.
7 resident service plans did not include frequencies of services and who would provide the service.
No policy provided that defined the level of nursing services provided by the facility.
2 residents did not have wander risk or secure unit agreements.
The CNA left the secure unit during the inspection.
No emergency evacuation plan in secure unit.
1 resident was not assessed to self-administer medications and had multiple medications at bedside.
1 resident did not receive medications per physician orders.
2 residents were assessed as independent with medication administration but were not able to independently administer medication.
1 resident did not have medications available and the health care professional was not notified of the medication error.
1 resident did not have medications available and no incident report was completed.
3 QA meetings did not have documentation that medication errors were incorporated into the QA process.
Not managing residents' funds according to requirements including lack of separate accounting and quarterly statements.
Nurses station computer unlocked with records not protected.
4 terminated employees did not have reason for leaving, first aid/CPR training, or TB tests documented.
4 residents' records did not contain name of dentist to be called in emergency.
Facility did not have incident reports for 3 residents' deaths.
1 resident on CCHO diet was not seen quarterly by a dietician.
No training documentation regarding housekeeping processes in 1 employee file.
Disinfectant wipes, spray, air freshener, paint, joint compound, ice machine cleaner, bleach, laundry detergent, hydrogen peroxide, dryer sheets, and other chemicals were improperly stored.
Scissors found at nurses station; oxygen and carbon monoxide tanks not secured; electrical panels unlocked; fire doors had gaps larger than 1/4 inch; fire alarm and sprinkler system last inspected in 2023.
Water temperature was 110.8 degrees Fahrenheit.
Missing emergency and disaster response plans for fire, severe weather, missing residents, death of residents, interruption of public utilities, explosions, earthquake, windstorm, and mass casualty.
No documentation of fire and disaster drills.
No extra blankets and radio in emergency supplies.
Emergency information not posted in prominent locations throughout the facility.
Report Facts
Number of rule noncompliances: 59
Training hours: 4
Employees not skin tested for TB: 3
Employees without health inventory form: 2
Resident assessments missing diagnosis: 1
Resident assessments not used for service plan: 7
Resident service plans missing frequencies and providers: 7
Residents missing wander risk or secure unit agreements: 2
Residents assessed independent but unable to self-administer medication: 2
Residents without medication incident reports: 1
Residents without medication available: 1
QA meetings without medication error documentation: 3
Residents records missing dentist contact: 4
Residents deaths without incident reports: 3
Residents on CCHO diet without quarterly dietician visit: 1
Employees missing housekeeping training documentation: 1
Residents without wander risk or secure unit agreements: 2
Employees missing reason for leaving, CPR, TB tests: 4
Residents without medication administration assessment: 1
Residents without medication available at bedside: 1
Residents without medication error incident report: 1
Residents without medication error notification: 1
Residents without incident reports for deaths: 3
Residents without quarterly financial statements: 0
Residents without separate accounting of funds: 0
Residents without secure storage of funds: 0
Residents without final accounting of funds upon discharge: 0
Residents without final accounting of funds within 30 days of death: 0
Loading inspection reports...
