Deficiencies (last 4 years)
Deficiencies (over 4 years)
16 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
103% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation triggered by a resident leaving the facility without proper supervision and being unaccounted for approximately 18 hours.
Complaint Details
The complaint investigation was substantiated. A resident left the facility without signing out or informing staff and was missing for about 18 hours. The night shift nurse falsified documentation about checking on the resident and was terminated. The resident was found safe and returned to the facility before discharge.
Findings
The facility failed to ensure adequate supervision to prevent accidents, as a resident left the facility without signing out or notifying staff and was missing for about 18 hours. The investigation revealed staff documentation falsification and inadequate resident monitoring, especially by agency staff unfamiliar with residents.
Deficiencies (1)
F 0689: The facility failed to ensure that a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents. A resident left the facility without notifying staff and was unaccounted for approximately 18 hours.
Report Facts
Duration resident missing: 18
Date survey completed: Nov 5, 2025
Resident discharge date: May 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Notified and involved in resident missing incident and investigation. | |
| Administrator | Interviewed resident and involved in investigation. | |
| Night shift nurse | Falsified documentation about resident checks and was terminated. | |
| Certified Nursing Assistants (CNA 2 and CNA 3) | Agency staff who provided information about resident rounding practices. | |
| Registered Nurse (RN 1) | Provided information about rounding and leave of absence procedures. |
Inspection Report
Routine
Deficiencies: 15
Date: Mar 6, 2025
Visit Reason
Routine state inspection of Rocky Mountain Care - Cottage on Vine to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including medication management errors, inadequate infection control documentation, failure to follow dietary portion sizes, improper food safety practices, incomplete laboratory records, and insufficient immunization documentation.
Deficiencies (15)
F 0554: The facility allowed a resident to self-administer medications without a clinical evaluation to ensure safety, resulting in potential medication risks.
F 0580: The facility failed to notify physicians of changes in treatment for residents, including catheter size changes and late antibiotic administration.
F 0582: The facility did not provide residents with notice of Medicaid/Medicare coverage and potential liability for services not covered, missing required Notice of Medicare Non-coverage for a resident.
F 0584: The facility did not maintain a sanitary, orderly, and comfortable environment; a resident's shower had persistent odors, stains, and buildup despite cleaning efforts.
F 0609: The facility failed to timely report an allegation of verbal abuse to the Administrator, State Survey Agency, and Adult Protective Services.
F 0610: The facility did not thoroughly investigate or report results of abuse/neglect allegations for two residents, lacking documentation of investigations.
F 0622: The facility failed to provide adequate documentation and communication during resident transfers to hospitals, missing transfer forms and assessments.
F 0690: The facility did not ensure residents received appropriate continence care or catheter care per physician orders, including use of incorrect catheter size and lack of toileting program for a resident.
F 0755: The facility did not provide routine and emergency drugs consistently; a resident missed doses of neuropathic pain medication due to pending delivery.
F 0760: The facility did not ensure residents were free from significant medication errors, including late or missed administration of phosphate binders and IV antibiotics, and failure to hold seizure medication as ordered.
F 0775: The facility did not maintain complete, dated laboratory records in residents' medical records, missing urinalysis and culture reports for multiple residents.
F 0803: The facility did not follow menus meeting nutritional needs; portion sizes were not measured or served according to menu specifications.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards; undated food items were found, dietary manager lacked hairnet, and sanitizer levels were not maintained properly.
F 0881: The facility lacked an infection prevention and control program that included monitoring antibiotic use; a resident's urinalysis and urine culture were not completed before antibiotic treatment.
F 0883: The facility did not ensure residents were offered influenza and pneumococcal immunizations with proper documentation of consent, education, and administration.
Report Facts
Missed medication doses: 5
Medication administration times: 13
Sanitizer PPM: 100
Sanitizer PPM: 300
Portion sizes: 3
Portion sizes: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Reported lack of 24 French suprapubic catheters in stock and inability to change catheter. |
| CNAC | Certified Nursing Assistant Coordinator | Responsible for ordering supplies including suprapubic catheters; did not reorder in time. |
| DON | Director of Nursing | Provided multiple interviews regarding medication administration, catheter issues, and infection control. |
| DM | Dietary Manager | Observed food portioning errors, undated food, and sanitizer issues in kitchen. |
| RD | Registered Dietitian | Discussed importance of following menus and proper sanitizing procedures. |
| IP | Infection Preventionist | Reported missing lab results and challenges with antibiotic stewardship. |
| LPN 1 | Licensed Practical Nurse | Reported on medication holding and lab ordering for resident with elevated lacosamide levels. |
| CN | Corporate Nurse | Confirmed missing pneumococcal vaccine documentation. |
| ADM | Administrator | Interviewed regarding late abuse reporting and investigations. |
Inspection Report
Routine
Deficiencies: 5
Date: Mar 3, 2025
Visit Reason
The inspection was an unannounced routine regulatory compliance check conducted by OL licensors to ensure facility adherence to nursing care facility regulations.
Findings
The inspection identified seven rule noncompliances related to various regulatory requirements including identification badges, resident care, medication administration, and facility policies. Several areas were found compliant, but some deficiencies were noted in documentation and procedural adherence.
Deficiencies (5)
R432-150-1-4 Identification Badges: The licensee failed to ensure all employees and volunteers wore identification badges with required information.
R432-150-14(4)(a-b) Incontinence Assessment: The licensee did not ensure a licensed nurse completed a written assessment of residents' ability to participate in bowel and bladder management programs.
R432-150-17(1) Pharmacy Services: The licensee did not provide or obtain by contract routine and emergency drugs, biologicals, and pharmaceutical services to meet each resident's physician's orders for medications.
R432-150-23(4)(a-r) Medical Records: The licensee failed to maintain complete individual medical records for each resident including required documentation such as advanced directives, discharge summaries, assessments, and informed consent.
R432-150-40-4 Vaccination Offer and Exemptions: The licensee did not fully comply with requirements to offer influenza, COVID-19, and pneumococcal vaccinations to employees and residents and document refusals or exemptions.
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 resident 10's self-injurious behaviors and lack of appropriate care planning and behavioral health services.
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 behavioral health services.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for residents with psychological and behavioral needs, specifically resident 10. Neurological assessments were not completed after falls, behavioral health services were not adequately provided, and medical records were not maintained timely or accurately.
Deficiencies (5)
F 0656: The facility failed to develop and implement a comprehensive care plan for resident 10 addressing mental health and falls despite multiple incidents and psychological needs.
F 0657: The facility did not ensure that resident 1 and resident 3 had care plans revised by the interdisciplinary team to address repeated behaviors and interventions.
F 0689: Resident 10 did not receive adequate supervision to prevent accidents; neurological assessments were not completed after falls.
F 0740: The facility did not provide necessary behavioral health care services to resident 10 to achieve the highest practicable well-being, including lack of mental health service documentation and observation.
F 0842: The facility did not maintain complete, accurate, and timely medical records for resident 10, with numerous progress notes documented as late entries.
Report Facts
Number of sampled residents: 11
Number of falls documented for resident 10: 8
Number of late progress notes for resident 10: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding care planning, behavioral health services, and neuro checks for resident 10 and others |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed about late charting practices and documentation |
| RN 1 | Registered Nurse | Interviewed about neuro checks and alert charting for resident 10 |
| LPN 1 | Licensed Practical Nurse | Interviewed about resident 10's depression and behavioral issues |
| CNA 1 | Certified Nursing Assistant | Interviewed about behavioral information access and resident 10's falls |
Inspection Report
Routine
Deficiencies: 8
Date: Nov 8, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, safety, abuse prevention, medication management, staffing, and provision of care including activities of daily living.
Findings
The facility was found deficient in multiple areas including failure to respect resident rights regarding catheter care consent, unsafe maintenance conditions, failure to prevent abuse, misappropriation of narcotics by a nurse, delayed reporting of abuse incidents, inadequate assistance with showers due to staffing shortages, and improper narcotic medication labeling and handling.
Deficiencies (8)
F0550: The facility did not ensure resident 8's right to dignified care by flushing and changing his catheter without consent, causing distress and potential harm.
F0584: Resident 14's toilet and toilet seat were not securely fastened, creating an unsafe environment and risk of injury.
F0600: Staff witnessed resident 7 inappropriately touching resident 6, but the allegation was not substantiated due to lack of recall and intent.
F0602: A nurse misappropriated narcotic medications from resident 10 after their expiration, leading to administrative leave and termination.
F0609: The facility failed to report allegations of abuse involving residents 2, 4, 5, and 9 within 2 hours as required by regulation.
F0677: Residents 3, 6, and 13 did not receive assistance with showers as scheduled due to staffing shortages and inadequate care provision.
F0725: The facility did not provide sufficient nursing staff to meet resident needs, resulting in missed showers and inadequate assistance for residents 3, 6, and 13.
F0761: Narcotics were improperly handled and relabeled by taping medication pockets after dispensing, increasing risk of medication errors and diversion.
Report Facts
Residents sampled: 20
Residents affected by catheter care issue: 1
Residents affected by unsafe toilet: 1
Residents affected by witnessed abuse: 2
Residents affected by narcotic misappropriation: 1
Residents affected by delayed abuse reporting: 4
Residents affected by missed showers: 3
Nursing staff counts: 4
Nursing staff counts: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 5 | Assistant Director of Nursing | Nurse terminated for narcotic misappropriation |
| RN 1 | Registered Nurse | Involved in catheter flushing and replacement without resident consent |
| RN 2 | Registered Nurse | Involved in catheter flushing and replacement without resident consent |
| CNA 11 | Certified Nurse Assistant | Witnessed resident 7 touching resident 6 inappropriately |
| DON | Director of Nursing | Provided statements on catheter care, narcotic handling, and staffing |
| DOO | Director of Operations | Involved in narcotic misappropriation investigation and abuse reporting |
Inspection Report
Routine
Deficiencies: 3
Date: Nov 8, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident safety, infection prevention and control, and immunization policies during a routine survey visit.
Findings
The facility was found deficient in maintaining a safe environment as a resident's toilet was unsecured. The infection prevention and control program was inadequate during a COVID-19 outbreak, with multiple failures in PPE use, isolation procedures, and environmental cleaning. Additionally, the facility failed to properly document education and declination for pneumococcal vaccination for one resident.
Deficiencies (3)
F 0584: The facility did not ensure maintenance services were provided to support safe daily living; a resident's toilet and toilet seat were not secured causing movement during use.
F 0880: The facility failed to maintain an infection prevention and control program during a COVID-19 outbreak, including improper use of PPE, lack of isolation precautions, failure to post outbreak notifications, and inadequate handling of COVID-19 positive residents' linens and utensils.
F 0883: The facility did not ensure that education regarding pneumococcal immunization benefits and side effects was provided, nor was there documentation of signed declination for the vaccine for one resident.
Report Facts
Residents sampled: 20
Residents affected: 1
Residents affected: 8
Residents sampled: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Observed not wearing full PPE in COVID-19 isolation room |
| CNA 2 | Certified Nursing Assistant | Observed not wearing PPE when entering COVID-19 isolation rooms and interacting with residents |
| CNA 4 | Certified Nursing Assistant | Observed not wearing PPE when entering isolation rooms and delivering care |
| CNA 5 | Certified Nursing Assistant | Interviewed about PPE use and observed doffing PPE incorrectly |
| LPN 1 | Licensed Practical Nurse | Observed entering COVID-19 isolation room without PPE and interviewed about PPE requirements |
| RN 4 | Registered Nurse | Interviewed about PPE use and facility COVID-19 policies |
| Director of Nursing | Director of Nursing | Interviewed regarding COVID-19 outbreak management and vaccination documentation |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding COVID-19 tracking and outbreak management |
| Interim Maintenance Manager | Interim Maintenance Manager | Interviewed regarding maintenance issues including unsecured toilet |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 21, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging inadequate investigation and supervision related to a resident elopement and concerns about laboratory services and infection control.
Complaint Details
The complaint involved allegations that the facility did not thoroughly investigate a resident elopement and failed to provide adequate supervision and safety measures. Additionally, concerns were raised about delays and deficiencies in laboratory testing and treatment for urinary tract infections.
Findings
The facility failed to conduct a thorough investigation following a resident elopement, resulting in inadequate supervision and safety measures. Additionally, the facility did not ensure timely and appropriate laboratory testing and treatment for residents with urinary tract infections, leading to hospitalizations.
Deficiencies (4)
F 0610: The facility did not ensure a thorough investigation of a resident elopement, failing to protect the resident from potential harm. Resident 6 eloped and the facility lacked evidence of a complete investigation to prevent future incidents.
F 0689: The facility failed to provide adequate supervision and assistive devices to prevent accidents, resulting in a resident eloping from the facility. Resident 6 was not adequately monitored despite known wandering behaviors.
F 0690: The facility did not ensure timely and appropriate treatment for residents with urinary tract infections. Resident 2 did not receive antibiotics promptly despite positive lab results, resulting in hospitalization for UTI, sepsis, and C. difficile infection.
F 0770: The facility failed to provide timely, quality laboratory services. Multiple attempts were needed to obtain urine samples and lab companies did not provide complete culture and sensitivity results, delaying treatment for residents 2 and 11 and resulting in hospitalizations.
Report Facts
Residents sampled: 15
Resident elopement risk score: 55
Lab result dates: 10
Medication duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 4 | Registered Nurse | Assisted in obtaining urine samples from Resident 2 and reported lab and treatment issues |
| RN 5 | Registered Nurse | Reported procedures for notifying providers of positive lab results |
| DON | Director of Nursing | Provided information on lab result follow-up procedures and investigation expectations |
| ADM | Administrator | Discussed facility policies on elopement investigations and lab service issues |
| UM 1 | Unit Manager | Described lab company issues and changes in lab result tracking protocols |
| MD 1 | Medical Director | Explained antibiotic treatment protocols based on culture and sensitivity results |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Date: Jun 15, 2023
Visit Reason
The inspection was conducted following a complaint regarding a resident fall incident where a resident requiring two-person assistance was rolled out of bed by a single staff member, resulting in injury.
Complaint Details
The complaint investigation was substantiated. Resident 11 fell out of bed during a brief change performed by a single CNA instead of two, resulting in a fractured rib. The facility conducted interviews and concluded no abuse or neglect. The CNA was educated previously on two-person transfers but was terminated after 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, leading to a resident sustaining a rib fracture. The investigation concluded no abuse or neglect but confirmed the staff member did not follow proper two-person assist protocol.
Deficiencies (1)
F 0689: The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents. A resident requiring two-person assistance was rolled out of bed by one staff member and sustained a rib fracture.
Report Facts
Residents sampled: 29
Resident weight: 350
Date of incident: Mar 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Staff member involved in the incident who performed the brief change alone |
| Assistant Director of Nursing | ADON | Interviewed regarding the incident and facility response |
| Corporate Resource Nurse | CRN | Interviewed about CNA 3's prior education on two-person transfers |
| CNA 4 | Certified Nursing Assistant | Interviewed confirming two-person assistance requirement |
| CNA 5 | Certified Nursing Assistant | Interviewed confirming two-person assistance requirement |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jun 15, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found to have multiple deficiencies including failure to prevent pressure ulcers, inadequate supervision leading to resident injury, lack of informed consent for bed rails, delayed and incomplete laboratory testing, and missing documentation of pneumococcal vaccine education and consent.
Deficiencies (5)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident unable to reposition independently.
F 0689: The facility failed to ensure a safe environment and adequate supervision, resulting in a resident being rolled out of bed and sustaining a rib fracture during a brief change.
F 0700: The facility failed to provide risk and benefits information or obtain informed consent for bed rails for a resident with half bedrails attached.
F 0770: The facility did not provide timely, quality laboratory services; a urinalysis took 22 days for results and another resident did not have ordered labs completed.
F 0883: The facility failed to document education and consent/refusal regarding pneumococcal immunization for two residents.
Report Facts
Residents sampled: 29
Pressure ulcer risk score: 14
Days delay for urinalysis results: 22
Resident weight: 350
Urine output: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Named in incident where resident 11 was rolled out of bed causing injury |
| LPN 1 | Licensed Practical Nurse | Involved in wound care and interviews regarding resident 21's pressure ulcer |
| RN 1 | Registered Nurse | Provided wound care and interviews regarding resident 21's pressure ulcer |
| ADON | Assistant Director of Nursing | Provided multiple interviews regarding incidents, policies, and deficiencies |
| CRN | Corporate Resource Nurse | Interviewed regarding staff education and lab result issues |
| LPN 2 | Licensed Practical Nurse | Interviewed regarding lab services and blood draws |
Inspection Report
Annual Inspection
Deficiencies: 17
Date: Jun 13, 2022
Visit Reason
The inspection was conducted as part of the annual recertification survey and to assess compliance with federal regulations regarding resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to protect residents from abuse and neglect, inadequate supervision of a resident with dementia and pica behaviors, failure to timely report and investigate abuse allegations, inadequate assistance with activities of daily living such as bathing, failure to maintain a safe and sanitary environment, medication management issues, and deficiencies in infection control practices. Immediate Jeopardy conditions were identified and subsequently abated during the survey period.
Deficiencies (17)
F584: The facility failed to protect residents' property from loss or theft and did not maintain a sanitary, orderly, and comfortable environment, including damage to walls in multiple resident rooms.
F600: The facility failed to ensure residents were free from abuse and neglect, including resident-to-resident physical abuse, spitting, and inadequate interventions to prevent recurrence, resulting in Immediate Jeopardy.
F609: The facility failed to timely report all alleged violations involving abuse, neglect, exploitation, or mistreatment to the State Survey Agency, resulting in Immediate Jeopardy.
F610: The facility failed to thoroughly investigate all alleged violations of abuse, neglect, exploitation, or mistreatment, including multiple resident-to-resident abuse incidents, resulting in Immediate Jeopardy.
F676: The facility failed to provide appropriate assistance with activities of daily living, including inconsistent showering and communication assistance for residents.
F689: The facility failed to provide adequate supervision and interventions to prevent a resident with dementia and pica from ingesting hazardous substances and non-food items, resulting in Immediate Jeopardy.
F689 (continued): The facility failed to secure hazardous chemicals properly, allowing a resident to access and ingest them, and failed to provide adequate staff education and supervision.
F689 (harm): A resident sustained injury during a transfer with a Hoyer lift, resulting in fractures and pain.
F744: The facility failed to provide appropriate treatment and services to residents with dementia, including inadequate behavioral interventions and management.
F756: The facility failed to ensure medication irregularities reported by the pharmacist were acted upon timely, resulting in prolonged administration of an anticoagulant after discontinuation.
F773: The facility failed to promptly notify the physician of laboratory results, specifically INR results, for a resident.
F779: The facility failed to keep signed and dated reports of x-rays in the resident's clinical record.
F804: The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature, resulting in multiple resident complaints.
F880: The facility failed to maintain an infection prevention and control program, including improper disposal of paracentesis fluid, failure to perform hand hygiene, and improper use of eye protection by staff.
F883: The facility failed to document resident education and consent/refusal for pneumococcal immunizations for sampled residents.
F886: The facility failed to ensure routine COVID-19 testing of staff based on vaccination status and community transmission rates.
F887: The facility failed to document resident education, consent/refusal, and administration of COVID-19 vaccinations and boosters for sampled residents.
Report Facts
Number of residents sampled: 39
Number of showers scheduled for resident 9: 30
Number of showers received by resident 9: 12
Number of showers scheduled for resident 17: 37
Number of showers received by resident 17: 25
Dates of Lorazepam administration for resident 29: 13
Dates of COVID-19 testing missed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Staffing Coordinator | Witnessed and reported resident 29 spitting and other behaviors |
| CNA 10 | Witnessed resident 29 eating non-edible items and reported staffing shortages | |
| Director of Nursing | DON | Provided multiple interviews regarding resident 29's behaviors and facility responses |
| Administrator | ADM | Provided interviews regarding facility policies and responses to abuse allegations |
| Housekeeping Supervisor | HS | Reported on laundry and chemical storage practices |
| Certified Nursing Assistant 1 | CNA 1 | Provided interviews about resident 29's behaviors and abuse reporting |
| Registered Nurse 4 | RN 4 | Observed and interviewed regarding infection control and resident care |
| Licensed Practical Nurse 3 | LPN 3 | Reported incidents involving resident 29 and medication administration |
| Restorative Nursing Assistant 1 | RNA 1 | Explained shower process and refusals |
| Employee 7 | Reported observations of resident 29's behaviors and incidents |
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