The Peaks at Clinton.

[R432-270-7(1)(a)-(n)] The provider was found out of compliance with R432-270-7(1)(k) for failing to ensure that suspected abuse, neglect, or exploitation was reported in accordance with Section 26B-6-205. During the inspection, it was determined that the facility failed to timely report suspicious bruising involving two residents to Adult Protective Services (APS). [R380-80-5(4)] The provider was out of compliance with R432-270-5(4) by not ensuring a resident was protected from abuse, harm, and mistreatment and any action that may have compromised the health and safety of clients through acts or omissions and did not instruct and encourage others to do the same. During the inspection, the licensor identified 2 residents with injuries of unknown origin that the facility failed to investigate as required.

[R432-270-18(14)] The provider was out of compliance with R432-270-(18)(14) by not ensuring the licensed health care professional was notified when medication errors occurred. During the inspection, the licensor observed 1 resident had multiple narcotic administrations documented solely on the narcotic count sheet, with no corresponding documentation entered into the medication administration record (MAR). The licensed health care professional was not documented to have notified when these medication errors occurred. [R432-270-18(19)(a)-(b)] The provider was out of compliance with R432-270-18(19)(a) by not ensuring policies were implemented for the destruction and disposal of outdated medications. During the inspection, the licensor observed the facility’s medication cart contained 1 resident’s outdated narcotic medication that had not been destroyed or properly disposed of. [R432-270-7(1)(a)-(n)] The provider was out of compliance with R432-270-7(1)(k) by not ensuring suspected exploitation and appropriate action was documented. During the inspection, the licensor noted that 1 employee had been terminated for suspicious narcotic administration involving a resident. Documentation was not completed by the facility regarding the employee’s alleged suspicious narcotic administration activity or the termination and corrective action taken afterward. [R432-270-20(3)(a)-(j)] The provider was out of compliance with R432-270-20(3) by not ensuring the personnel records were maintained and available for review. During the inspection, the licensor requested the personnel record for 1 former employee. The personnel record was not available for review. [R432-270-14(3)(a)-(c)] The provider was out of compliance with R432-270-14(3)(c) by not ensuring that the delegated routine nursing tasks were completed. During the inspection, the licensor observed that the medication technicians did not document that the registered nurse’s approval was obtained prior to the administration of as needed medications. [R432-270-5(1)(a)-(d)] The provider was out of compliance with R432-270-5(1)(c) by not establishing policies and procedures for the general operation of the facility. During the inspection, the licensor observed that the staff were not completing the narcotic count shift change documentation according to facility policy. [R432-270-18(7)(a)-(f)] The provider was out of compliance with R432-270-18(7)(d) by not ensuring medications were administered according to the prescribing order. During the inspection, the licensor observed that 1 resident had an active PRN narcotic order that was documented as administered in September 2025, but the medication for this order was never filled by the pharmacy, was not present in the medication cart, and was unavailable for actual administration. [R432-270-18(15)] The provider was out of compliance with R432-270-18(15) by not ensuring that medication error incident reports were completed. During the inspection, the licensor observed documentation that 1 resident was administered an unordered narcotic several times and no medication error incident reports were completed.

[R380-600-3(25)] The provider was out of compliance with rule R380-600-3(25) by not posting their current license in a readily visible location to the public. Specifically, the licensor observed that the posted license was not current and listed a previous administrator and management company. This is a repeat non-compliance from the inspection conducted on June 30, 2025 [R432-270-21(6)] The provider was out of compliance with rule R432-270-(21)(6) by not ensuring the inspection report by the local health department was maintained at the facility. Specifically, the licensor observed that the facility did not maintain the kitchen’s county health department inspection, and the certificate on display was outdated. This is a repeat non-compliance from the inspection conducted on June 30, 2025.

[R432-270-10(5)(a)-(x)] The provider was out of compliance with rule R432-270-10(5)(m) by not ensuring that residents had access to telephones to make and receive private calls. During the inspection, the licensor observed that the facility phone system did not allow incoming calls and employees were using personal phone numbers to make and receive calls with residents’ families and outside providers.

[R432-270-19(7)(a)-(f)] The provider was out of compliance with R432-270-19(7)(b) by not ensuring that facility staff administered medications only after delegation by a licensed health care professional under the scope of their practice. During the inspection, documentation of medication delegations for 5 unlicensed facility staff who administered medications was not provided to the licensor upon request. [R432-270-15(3)(a)-(c)] The provider was out of compliance with R432-270-15(3)(a-c) by not ensuring a registered nurse was employed or contracted to provide or supervise nursing services, including a nursing assessment on each resident, general health monitoring on each resident, and routine nursing tasks. During the inspection, the licensor identified that the provider had not employed or contracted a registered nurse to provide or supervise nursing services. [R432-270-13(1)] The provider was out of compliance with R432-270-13(1) by not ensuring a signed and dated resident assessment was completed for each resident before admission and at least every six months. During the inspection, the licensor identified that assessments for 2 residents were not completed before admission, and assessments for another 2 residents were not completed at least every six months.<br/><br/>This is a repeat non-compliance from the inspections dated July 1, 2024, and July 31, 2024.

[R432-270-13(5)] The licensee was out of compliance with R432-270-13(5) by neglecting to revise and update the assessments of two residents after a significant change occurred. During the inspection, the licensor observed that two residents, who had documented significant changes and were admitted to hospice, lacked completed significant change assessments. This was a repeat noncompliance as noted on 01/06/2025.