Deficiencies (last 4 years)
Deficiencies (over 4 years)
14.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
87% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident who left the facility unaccounted for approximately 18 hours before staff were alerted.
Complaint Details
The complaint investigation found that resident 3 left the facility without notifying staff and was missing for approximately 18 hours. The resident was found in good condition after traveling to Salt Lake City and a friend's house. The night shift nurse falsified documentation and was terminated. Agency staff were not fully familiar with residents. The resident was discharged to an assisted living facility on 5/28/25.
Findings
The facility failed to ensure adequate supervision to prevent accidents, as a resident left without signing out or informing staff and was missing for about 18 hours. The investigation revealed lapses in staff supervision and documentation, including falsified records by a night shift nurse and unfamiliarity of agency staff with residents.
Deficiencies (1)
Failure to ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Duration resident was unaccounted for: 18
Resident discharge date: 52825
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Notified about resident absence, involved in investigation, and stated night shift nurse was terminated for falsifying documentation. |
| Night shift nurse | Falsified documentation about checking on resident 3 and was terminated. |
Inspection Report
Routine
Deficiencies: 15
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident care, medication management, infection control, abuse reporting, dietary services, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including medication self-administration safety, failure to notify physicians of treatment changes, inadequate notification of Medicare non-coverage, unsanitary shower conditions, delayed reporting of abuse allegations, incomplete abuse investigations, improper resident transfers without documentation, inadequate catheter care, medication availability issues, incomplete laboratory records, failure to follow nutritional menus, food safety violations, lack of antibiotic stewardship, and incomplete immunization documentation.
Deficiencies (15)
Facility did not ensure resident right to self-administer medications was clinically appropriate and safe for 1 of 27 sampled residents.
Facility did not notify and consult with physician when resident's treatment was altered for 2 of 27 sampled residents.
Facility did not issue Notice of Medicare Non-coverage (NOMNC) when Medicare Part A services were terminated for 1 of 3 sampled residents.
Facility did not maintain sanitary, orderly, and comfortable shower environment for 1 of 27 sampled residents.
Facility failed to timely report alleged verbal abuse to Administrator, State Survey Agency, and Adult Protective Services for 1 of 27 sampled residents.
Facility failed to thoroughly investigate and report results of abuse/neglect allegations for 2 of 27 sampled residents.
Facility did not ensure adequate documentation and communication during resident hospital transfers for 2 of 27 sampled residents.
Facility did not ensure residents with bladder incontinence received appropriate toileting assistance and catheter care for 2 of 27 sampled residents.
Facility did not provide prescribed medication to manage neuropathic pain due to pending delivery for 1 of 27 sampled residents.
Facility did not ensure residents were free from significant medication errors including delayed or missed medications and failure to hold medication as ordered for 3 of 27 sampled residents.
Facility did not keep complete, dated laboratory records in residents' medical records for 4 of 27 sampled residents.
Facility did not follow menus that met nutritional needs of residents and did not provide correct portion sizes.
Facility did not store, prepare, distribute, and serve food in accordance with professional standards including undated food, dietary manager not wearing hair net, and sanitizer levels not at required levels.
Facility did not implement a program that monitors antibiotic use; resident's urinalysis and urine culture and sensitivity was not completed.
Facility did not ensure residents were offered influenza and pneumococcal immunizations with proper documentation of consent, education, and administration.
Report Facts
Deficiencies cited: 15
Residents sampled: 27
Medication missed doses: 5
Medication administration times: 13
Medication administration times: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant Coordinator (CNAC) | Certified Nursing Assistant Coordinator | Named in verbal abuse reporting deficiency and medication supply ordering |
| Director of Nursing (DON) | Director of Nursing | Named in multiple findings including medication administration, abuse reporting, and infection control |
| Registered Nurse (RN) 1 | Registered Nurse | Named in medication administration and catheter care findings |
| Licensed Practical Nurse (LPN) 1 | Licensed Practical Nurse | Named in medication administration and lab reporting findings |
| Dietary Manager (DM) | Dietary Manager | Named in food service and sanitation deficiencies |
| Registered Dietitian (RD) | Registered Dietitian | Named in food service and sanitation deficiencies |
| Infection Preventionist (IP) | Infection Preventionist | Named in antibiotic stewardship and lab reporting deficiencies |
| Nurse Practitioner (NP) | Nurse Practitioner | Named in antibiotic stewardship and lab reporting deficiencies |
| Administrator (ADM) | Administrator | Named in abuse reporting and investigation deficiencies |
Inspection Report
Routine
Deficiencies: 1
Date: Mar 3, 2025
Visit Reason
The inspection was an unannounced routine inspection conducted to ensure compliance with nursing care facility regulations.
Findings
The inspection identified 7 rule noncompliances related to various regulatory requirements for nursing care facilities, including policies, procedures, resident care, and facility maintenance.
Deficiencies (1)
Seven rule noncompliances were identified during the inspection.
Report Facts
Number of rule noncompliances: 7
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 15, 2024
Visit Reason
The inspection was conducted following a complaint regarding inadequate care planning and supervision for residents with psychological and behavioral health needs, including self-harm and falls.
Complaint Details
Complaint submitted on 2024-05-03 regarding resident 10's history of self-injurious behaviors and lack of protocol for self-harm or suicidal ideation. The complaint was substantiated by findings of inadequate care planning and supervision.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for residents with psychological and behavioral needs, did not provide adequate supervision to prevent accidents, failed to provide necessary behavioral health care services, and did not maintain timely and accurate medical records. Specifically, resident 10 had multiple falls without appropriate care plans or neurological assessments, self-harm incidents without proper mental health interventions, and late documentation of progress notes.
Deficiencies (5)
Failed to develop and implement a comprehensive care plan for resident with psychological needs and multiple falls.
Failed to develop the complete care plan within 7 days of the comprehensive assessment; care plan not revised by interdisciplinary team for residents with behavioral issues.
Did not ensure adequate supervision to prevent accidents; neurological assessments not completed after falls.
Did not provide necessary behavioral health care and services to achieve highest practicable well-being; resident with psychological diagnoses and self-harm was not offered behavioral health services.
Did not maintain complete, accurate, and timely medical records; progress notes were documented late and not by staff directly involved in care.
Report Facts
Falls documented: 8
Late progress notes: 26
Residents sampled: 11
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care planning, supervision, and mental health services for resident 10. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding late charting practices and documentation of resident care. |
| RN 1 | Registered Nurse | Interviewed about neuro checks and resident 10's behavior. |
| LPN 1 | Licensed Practical Nurse | Interviewed about resident 10's depression and alert charting. |
| CNA 1 | Certified Nursing Assistant | Interviewed about behavioral issues reporting and use of CNA brain book. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 8, 2023
Visit Reason
The inspection was conducted based on complaints regarding maintenance issues, infection prevention and control deficiencies during a COVID-19 outbreak, and vaccination policy compliance at Rocky Mountain Care - Cottage on Vine.
Complaint Details
The complaint investigation included issues with maintenance (toilet safety), infection control failures during a COVID-19 outbreak affecting 8 of 20 sampled residents, and vaccination policy noncompliance for 1 of 5 sampled residents.
Findings
The facility was found deficient in maintaining a safe environment due to unsecured toilets, inadequate infection prevention and control practices during a COVID-19 outbreak affecting multiple residents, and failure to properly document pneumococcal vaccination education and declination for a resident.
Deficiencies (3)
Resident's toilet and toilet seat were not secured to the floor causing movement during use.
Facility did not maintain an infection prevention and control program during a COVID-19 outbreak, including failure to perform contact and droplet precautions, hand hygiene, posting outbreak notifications, use of disposable utensils, and proper isolation and laundering of COVID-19 positive residents' linens.
Facility did not ensure education was provided or documented before offering pneumococcal immunization, and resident records lacked signed declination or education documentation.
Report Facts
Residents sampled: 20
Residents affected: 8
Residents sampled: 5
Residents affected: 1
Residents sampled: 20
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Observed not wearing full PPE during medication administration in COVID-19 positive resident's room |
| CNA 2 | Certified Nursing Assistant | Observed multiple times not wearing PPE when entering COVID-19 positive residents' rooms and riding motorized wheelchair without mask |
| CNA 4 | Certified Nursing Assistant | Observed delivering juice without PPE in isolation room and then serving non-isolation residents |
| CNA 5 | Certified Nursing Assistant | Observed donning surgical mask, gown, and gloves but not doffing mask after exiting isolation room |
| LPN 1 | Licensed Practical Nurse | Observed entering COVID-19 positive resident room without PPE |
| RN 4 | Registered Nurse | Observed multiple times without face mask at nurse's station and interviewed about PPE use |
| Director of Nursing | Director of Nursing | Interviewed regarding outbreak management, infection control policies, and vaccination documentation |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding COVID-19 tracking and outbreak response |
| Interim Maintenance Manager | Interim Maintenance Manager | Interviewed regarding maintenance concerns and response procedures |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Nov 8, 2023
Visit Reason
The inspection was conducted due to multiple complaints and allegations regarding resident care, abuse, neglect, and medication misappropriation at Rocky Mountain Care - Cottage on Vine.
Complaint Details
The investigation was complaint-driven, involving allegations of forced catheter care without consent, unsafe facility maintenance, witnessed resident-to-resident sexual abuse, narcotic medication misappropriation by a nurse, delayed abuse reporting, inadequate assistance with activities of daily living, and improper medication handling.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights to dignity and consent, unsafe maintenance conditions, failure to prevent abuse, misappropriation of narcotic medications by a nurse, delayed reporting of abuse allegations, insufficient assistance with activities of daily living including showers, and improper narcotic medication handling and labeling.
Deficiencies (8)
Failure to honor resident's right to a dignified existence and to obtain consent for catheter care.
Unsafe maintenance services: resident's toilet and toilet seat were not secured causing movement during use.
Failure to ensure residents remained free from abuse; witnessed inappropriate touching between residents.
Misappropriation of narcotic medications by a nurse, including possession of expired narcotics.
Failure to timely report suspected abuse and results of investigations to proper authorities.
Failure to provide necessary assistance with activities of daily living, including showers, per resident schedules.
Insufficient nursing staff to meet resident needs, resulting in missed showers and inadequate assistance.
Failure to label and store drugs and biologicals properly; narcotics were repackaged into narcotic cards and taped back improperly.
Report Facts
Residents sampled: 20
Residents affected by deficiencies: 8
Days lapsed between showers: 12
Narcotic pocket numbers taped: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Involved in catheter care incident with resident 8 |
| RN 2 | Registered Nurse | Involved in catheter care incident with resident 8 |
| CNA 4 | Certified Nurse Assistant | Witnessed resident 8's distress after catheter incident |
| LPN 1 | Licensed Practical Nurse | Provided information on catheter care policies |
| LPN 3 | Licensed Practical Nurse | Provided information on catheter care policies |
| DON | Director of Nursing | Provided multiple interviews regarding catheter care, abuse investigations, and narcotic handling |
| CNA 11 | Certified Nurse Assistant | Witnessed resident-to-resident inappropriate touching |
| RN 5 | Registered Nurse | Narcotic misappropriation allegation and termination |
| LPN 2 | Licensed Practical Nurse | Provided statement regarding witnessed abuse incident |
| SW | Social Worker | Conducted abuse investigation interviews |
| DOO | Director of Operations | Provided information on abuse reporting and narcotic misappropriation |
| CNA 7 | Certified Nurse Assistant | Reported understaffing and missed showers |
| CNA 8 | Certified Nurse Assistant | Reported missed showers and insufficient staffing |
| CNA 9 | Certified Nurse Assistant | Reported resident 13 required assistance with showers |
| CNA 10 | Certified Nurse Assistant | Reported resident 13 required standby assistance with showers |
| RN 3 | Registered Nurse | Provided information on narcotic count and handling |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 21, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding alleged violations related to resident elopement and inadequate investigation of the incident at Rocky Mountain Care - Cottage on Vine.
Complaint Details
The complaint investigation focused on allegations of abuse, neglect, exploitation, and mistreatment related to resident elopement and inadequate investigation of the incident. The facility was found to have failed in conducting a complete investigation and ensuring resident safety.
Findings
The facility failed to thoroughly investigate an elopement incident involving resident 6, who left the building unattended. The investigation revealed inadequate supervision and security measures, including an unlocked gate and alarm issues. Additionally, the facility did not ensure timely and appropriate treatment for residents with urinary tract infections, resulting in hospitalizations for residents 2 and 11.
Deficiencies (4)
Failure to thoroughly investigate an elopement incident involving resident 6.
Failure to ensure adequate supervision and assistive devices to prevent accidents, resulting in resident 6 eloping from the facility.
Failure to provide appropriate care for residents incontinent of bladder to prevent urinary tract infections, resulting in delayed treatment and hospitalization of resident 2.
Failure to provide timely, quality laboratory services/tests to meet residents' needs, resulting in delayed antibiotic treatment and hospitalization of resident 11.
Report Facts
Residents sampled: 15
Resident elopement risk score: 55
Temperature: 99
Vital signs: Resident 6's vitals during elopement incident: respiration 16, BP 129/68, pulse 107, SPO2 95, temperature 98.7 F
Lab result dates: 10
Medication duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Interviewed regarding resident 6's wandering behaviors and elopement incident |
| LPN 1 | Licensed Practical Nurse | Interviewed regarding resident 6's wandering behaviors and gate alarm incident |
| RN 1 | Registered Nurse | Interviewed regarding resident 6's elopement and behaviors |
| RN 2 | Registered Nurse | Interviewed regarding missing resident protocols and elopement |
| CNA 2 | Certified Nursing Assistant | Interviewed regarding missing resident protocols and elopement |
| CNA 3 | Certified Nursing Assistant | Interviewed regarding missing resident protocols and elopement |
| RN 4 | Registered Nurse | Interviewed regarding resident 2's UTI symptoms and lab handling |
| RN 5 | Registered Nurse | Interviewed regarding lab result notification procedures |
| DON | Director of Nursing | Interviewed regarding lab result handling, elopement investigation, and facility protocols |
| ADM | Administrator | Interviewed regarding gate security, elopement investigation, and laboratory service issues |
| UM 1 | Unit Manager | Interviewed regarding laboratory service issues and staff education |
| MD 1 | Medical Director | Interviewed regarding treatment protocols for positive urine cultures |
| SSW | Social Service Worker | Interviewed regarding lack of investigation into resident 6's elopement |
| GS 1 | Groundskeeping Staff Member | Interviewed regarding gate security and resident supervision |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 15, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements and evaluate the quality of care and safety at Rocky Mountain Care - Cottage on Vine.
Findings
The facility was found deficient in multiple areas including pressure ulcer care, accident prevention, laboratory services timeliness, bed rail consent, and pneumococcal vaccination documentation. Specific residents were identified with issues such as pressure ulcers due to inadequate repositioning, a resident fall resulting in a rib fracture, delayed lab results, missing lab orders, lack of informed consent for bed rails, and missing pneumococcal vaccine education and consent documentation.
Deficiencies (5)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for resident 21.
Failure to ensure resident environment was free from accident hazards and provide adequate supervision, resulting in resident 11 falling out of bed and sustaining a rib fracture.
Failure to provide risk and benefits information and obtain informed consent for bed rails for resident 24.
Failure to provide timely, quality laboratory services/tests, including delayed urinalysis results and missing lab orders for residents 11 and 26.
Failure to develop and implement policies and procedures ensuring documentation of education and consent/refusal for pneumococcal vaccinations for residents 24 and 32.
Report Facts
Residents sampled: 29
Pressure ulcer risk score: 14
Days delay in lab results: 22
Resident weight: 350
Pressure ulcer size: 0.8
Pressure ulcer size: 0.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Named in fall incident involving resident 11 |
| LPN 1 | Licensed Practical Nurse | Involved in wound care and interviews regarding resident 21 |
| RN 1 | Registered Nurse | Interviewed regarding wound care and repositioning of resident 21 |
| ADON | Assistant Director of Nursing | Interviewed regarding multiple findings including wound care, fall incident, lab results, and vaccination education |
| CRN | Corporate Resource Nurse | Interviewed regarding fall incident and bed rail consent |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding lab services and blood draws |
| RN 2 | Registered Nurse | Interviewed regarding lab result follow-up procedures |
| MS | Maintenance Staff | Interviewed regarding bed rail condition for resident 24 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 15, 2023
Visit Reason
The inspection was conducted following a complaint related to a resident fall incident where a resident requiring two-person assistance was injured during a brief change with only one staff member present.
Complaint Details
The complaint investigation involved a resident (Resident 11) who required two-person assistance but was assisted by only one CNA during a brief change on 3/17/23, resulting in the resident falling out of bed and sustaining a rib fracture. The investigation included interviews with the resident, CNA 3, other CNAs, the Corporate Resource Nurse, and the Assistant Director of Nursing. The facility concluded there was no abuse or neglect and no malintent by CNA 3. The facility terminated CNA 3's employment following the incident.
Findings
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision during a brief change, resulting in a resident falling out of bed and sustaining a rib fracture. The investigation concluded no abuse or neglect but confirmed the staff member did not follow proper two-person assist protocols.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident falling and sustaining a rib fracture.
Report Facts
Residents sampled: 29
Resident weight: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Staff member involved in the incident resulting in resident fall |
| Corporate Resource Nurse | Corporate Resource Nurse | Interviewed regarding CNA 3's prior education and facility actions |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding the incident and facility's attempts to obtain hospital records |
Inspection Report
Annual Inspection
Deficiencies: 16
Date: Jun 13, 2022
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with state and federal regulations for Rocky Mountain Care - Cottage on Vine.
Findings
The facility was found deficient in multiple areas including resident property protection, abuse prevention and investigation, care and assistance with activities of daily living, infection control, medication management, and food quality. Immediate Jeopardy was identified related to abuse, neglect, and safety hazards involving resident 29 and others. The facility implemented abatement plans and education to address these issues.
Deficiencies (16)
Facility did not have an effective system to protect resident property from loss or theft; multiple resident rooms had damage to walls.
Facility failed to ensure residents were free from abuse and neglect; Immediate Jeopardy identified related to resident 29's aggressive behaviors including hitting, spitting, and wandering.
Facility failed to timely report all alleged violations involving abuse, neglect, exploitation, or mistreatment to the State Survey Agency; Immediate Jeopardy identified.
Facility failed to thoroughly investigate all alleged violations of abuse and neglect; Immediate Jeopardy identified.
Resident 29 had significant behavioral issues including wandering, spitting, and ingesting non-edible items; facility failed to provide appropriate interventions and supervision.
Resident 9 was not provided assistance with showers as scheduled, missing many showers without documentation of refusals.
Resident 17 was not provided showers according to schedule; multiple missed showers documented.
Resident 29 had significant communication barriers due to language and cognitive impairment; facility failed to implement adequate communication interventions.
Resident 11 sustained injury during transfer with Hoyer lift; facility provided education to staff but could not identify responsible staff member.
Facility failed to maintain infection prevention and control program; improper disposal of paracentesis fluid, inadequate hand hygiene, and lack of appropriate eye protection observed.
Facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature; multiple residents complained about food quality and repetition.
Facility failed to act timely on pharmacist's medication irregularity report; resident received anticoagulant medication for 7 days after physician discontinued it.
Facility failed to promptly notify physician of lab results; physician was not notified of resident's INR results for several months.
Facility failed to keep signed and dated x-ray reports in resident's clinical record; resident's x-ray report was missing.
Facility failed to ensure residents received education, consent, and documentation for pneumococcal and COVID-19 vaccinations; documentation was missing for some residents.
Facility failed to ensure routine COVID-19 testing of staff based on vaccination status and county positivity rate; multiple staff missed required testing.
Report Facts
Shower frequency: 12
Shower frequency: 25
Medication days: 7
INR lab results: 6
Staff missing COVID tests: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee 7 | Witnessed resident 29 behaviors including eating non-edible items and reported glove incident. | |
| LPN 4 | Licensed Practical Nurse | Staffing Coordinator; witnessed glove removal from resident 29's mouth; reported incidents to DON and Social Worker. |
| DON | Director of Nursing | Provided multiple interviews regarding resident 29's behaviors, investigations, and staff education. |
| ADM | Administrator | Provided interviews regarding resident 29's behaviors, staff COVID testing, and facility policies. |
| CNA 10 | Certified Nursing Assistant | Witnessed resident 29 eating non-edible items and reported to nurse. |
| RN 4 | Registered Nurse | Observed with improper eye protection; provided interviews on resident 29 care and communication. |
| RNA 1 | Restorative Nursing Assistant | Explained shower process and documentation requirements. |
| CNA 2 | Certified Nursing Assistant | Explained shower scheduling and refusal documentation. |
| RN 5 | Registered Nurse | Explained shower procedures and documentation. |
| ADON | Assistant Director of Nursing | Provided multiple interviews regarding immunizations, COVID testing, and shower documentation. |
| CNA 4 | Certified Nursing Assistant | Described Hoyer lift use with resident 11. |
| CNA 5 | Certified Nursing Assistant | Described Hoyer lift use with resident 11. |
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