Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rocky Mountain Care - Willow Springs during CMS and state inspections, most recent first.
The facility failed to timely report alleged abuse to SSA and APS after staff twice observed a resident with dementia and acute systolic CHF receiving zealous, open-mouthed kisses on the mouth from her brother. On two separate occasions, a CNA and an LPN witnessed or were informed of these unusual kissing interactions, which they later described as awkward and not typical of a sibling relationship. Despite this, the nursing staff did not immediately report the incidents as potential abuse to the Administrator, and the allegation was not brought forward until a staff meeting days later, resulting in the required notifications to external authorities not being made within the mandated 2-hour timeframe.
A resident with muscle weakness, gait abnormalities, atrial fibrillation, and on a blood thinner sustained an unwitnessed bathroom fall, reported hitting her head, and developed rapidly worsening right facial swelling and a swollen‑shut eye that prevented pupillary assessment. Initial vitals and neuro checks were performed, oxygen was applied, and x‑rays were ordered, but despite the significant change in condition and the resident’s anticoagulation status, the provider was not notified of the worsening condition at the time it occurred and the resident was not sent to the hospital until the next day when an NP assessed her and ordered transfer. In the ED, the physician documented that no evaluation for the injuries had occurred the prior evening and CT imaging showed traumatic subdural and subarachnoid hemorrhages and a large facial hematoma, demonstrating that the facility failed to provide timely, standard‑of‑care treatment and hospital transfer after the fall and subsequent change in condition.
A resident with cognitive impairment, neurological conditions, and substance-related diagnoses was assessed as being at risk for elopement and documented as having poor safety awareness, poor judgment, and wandering behavior requiring frequent redirection. Nursing staff observed the resident wandering in the hall and behind the nurse’s station and communicated during shift report that a WanderGuard was recommended, but no device was applied because staff did not know where to obtain one. The resident later left the building through the front door, was not immediately detected as missing, and was ultimately found by a medication technician about a mile away walking on a sidewalk near a restaurant, demonstrating a failure to provide adequate supervision and timely elopement interventions.
A resident with complex medical needs, assessed as requiring extensive two-person assistance for bed mobility, fell from bed and sustained serious injuries during a one-person assist for incontinence care. Staff were unclear about the required level of assistance, and the resident's care plan and KARDEX did not consistently reflect her needs, leading to inadequate supervision and a preventable accident.
A resident with COPD, emphysema, and a-fib was allowed to self-administer multiple inhalers without a documented assessment by the facility's interdisciplinary team, as required by policy. Nursing staff and the DON were unaware that the resident had several inhalers at bedside and had not reassessed her ability to safely self-administer medications after her initial admission.
A resident was admitted to hospice care and experienced changes in medication, but the facility did not complete a Significant Change MDS assessment within the required 14-day period. MDS Coordinators confirmed that this assessment should have been performed following the initiation of hospice services.
A resident with multiple chronic conditions was found with a cup of 13 pills left unattended at her bedside, and the nurse who administered the medications did not supervise or verify their consumption. The resident's care plan required medications to be administered as prescribed and monitored for side effects, but staff interviews confirmed that the standard practice of observing medication intake was not followed. The DON acknowledged that medication should not be left at the bedside and that the timing of administration was important, especially for medications with specific schedules.
A resident with multiple chronic conditions had a physician's order for a vaginal culture due to vaginal discharge, but the resulting laboratory report was not filed in the electronic medical record. Staff confirmed that the lab results from an outside facility were not requested or uploaded as required.
A resident with chronic pain and multiple diagnoses received narcotic pain medication that was documented in the narcotic record book but not signed out as administered on the MAR. Staff interviews confirmed the medication was given, but the required documentation on the MAR was missing, resulting in incomplete and inaccurate medical records.
A facility failed to prevent significant medication errors for several residents, including one who received another's medications, leading to hospitalization. Other residents received incorrect dosages or medications not aligned with physician orders, including one with a known allergy. The errors were acknowledged by the DON and documented in medical records.
A resident with multiple health conditions fell and sustained injuries after being left unattended during a brief change. The facility's investigation into the incident was incomplete, lacking interviews with key staff and the resident. The CNA reported the resident attempted to retrieve a stuffed dog from the floor, leading to the fall. The investigation concluded without verifying neglect, highlighting a failure to conduct a thorough investigation.
A resident with a history of falls and requiring a Hoyer lift for transfers was manually lifted by two staff members due to a Hoyer lift battery failure, resulting in an assisted fall and shoulder pain. The resident was sent to the emergency department, where no acute fracture was found, but a likely rotator cuff injury was noted. The incident revealed a failure to ensure equipment functionality and adherence to the care plan.
Failure to Timely Report Alleged Sexual Abuse to SSA and APS
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) and Adult Protective Services (APS). Resident 3, who was admitted with unspecified dementia and acute systolic congestive heart failure, was involved in two separate incidents in which her brother was observed kissing her on the mouth in a manner staff described as zealous, enthusiastic, sloppy, and not typical of a brother-sister interaction. On 12/28/25, CNA 1 observed a well-dressed man enter Resident 3's room, hug her, and give her a zealous kiss on the mouth. CNA 1 assumed the man was the resident's husband and reported this to LPN 1, who knew the visitor was the resident's brother. LPN 1 looked into the room and did not see anything out of the ordinary, and neither CNA 1 nor LPN 1 reported this incident as a potential allegation of abuse to the Administrator at that time. On 1/4/26, LPN 1 and CNA 1 entered Resident 3's room to address the resident's pain and request for catheter removal and to assist with a brief and linen change. Resident 3 had two visitors present, including her brother. When asked to step out for privacy, the female visitor left, but the brother hesitated and then gave Resident 3 a sloppy, open-mouthed kiss on the mouth lasting about three seconds, again in the presence of staff. The brother stated that Resident 3 was his older sister and that she had taken care of him since they were very small. LPN 1 did not report either the 12/28/25 or 1/4/26 kissing incidents to the Administrator. The Administrator later stated that the alleged abuse was first mentioned during a meeting on 1/6/26, at which time staff described the kiss as a weird, awkward kiss and not a typical brother-sister kiss, and acknowledged that nursing staff had not reported the suspicious activity in a timely manner, resulting in failure to notify SSA and APS within two hours of the allegation.
Delayed Hospital Transfer After Fall With Head Trauma and Anticoagulation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident who experienced a fall with head trauma and was on anticoagulation received timely treatment and care in accordance with professional standards of practice. The resident had diagnoses including generalized muscle weakness, gait and mobility abnormalities, and unspecified atrial fibrillation, and was on a blood thinner. On the evening of the fall, nursing documentation showed that the resident was found on the bathroom floor after her roommate called out. The resident reported hitting her head, had facial pain rated 5/10, and initial vital signs showed an O2 saturation of 88–90% with other vitals within normal limits. A neurological assessment was initiated, oxygen was applied, and the on‑call provider was notified, who ordered x‑rays of the resident’s head and left hand. As the evening progressed, the resident’s condition changed. The nurse documented that the resident’s right eye became increasingly swollen to the point that by 9:15 PM it was swollen shut and pupillary reactivity could no longer be assessed, while the left eye remained equal and reactive to light. The neurological exam form recorded that the provider was notified of the fall at 8:00 PM, but did not indicate that the provider was notified when the right eye became swollen shut at 9:15 PM. The DON later stated that this change in the resident’s condition occurred at 9:15 PM and that the medical provider was not notified of this change until the provider came to the facility the following day. The DON also stated that if a resident on a blood thinner experienced a fall with head strike, she expected staff to send the resident to the hospital, and that she was not sure why this resident was not immediately sent. The resident remained in the facility overnight while x‑rays were obtained around 1:00–1:30 AM, with results reportedly available sometime between early morning hours and mid‑morning. The next morning, the NP assessed the resident due to the fall and documented significant right facial swelling, focal tenderness over the zygoma, difficulty visualizing the right eye, and concern for occult injury and possible orbital blowout fracture in the context of anticoagulation. The NP ordered transfer to the emergency department for CT imaging of the head and face. In the emergency department, the physician documented that no evaluation for the resident’s injuries had occurred the previous evening and that the facility had reported the resident seemed slightly altered the prior night and had worsening swelling by the time EMS was called. CT imaging revealed traumatic small subdural and subarachnoid hemorrhages without mass effect and a large facial hematoma. Interviews with nursing staff showed that the RN on duty was very concerned about the resident’s rapidly increasing facial swelling and difficulty administering medications due to lip swelling, but was waiting for a physician order to send the resident to the hospital and was unaware at the time that she could initiate a hospital transfer without such an order. These actions and inactions resulted in a delay in sending the resident to the hospital after a significant change in condition following a fall with head trauma while on a blood thinner. The facility’s Change of Condition/SBAR Evaluation Policy outlined expectations for describing changes in condition, documenting vital signs, identifying changes from baseline (including neurological status changes), and notifying the provider and responsible party, as well as documenting immediate actions and outcomes such as transfer to the hospital. Despite this policy, the neurological exam form did not reflect timely provider notification when the resident’s right eye became swollen shut, and the resident was not transferred until the following day after the NP’s in‑person assessment. The DON confirmed that the change in condition at 9:15 PM was not communicated to the provider until the next day. The surveyors determined that, for this resident, the facility did not ensure timely hospital transfer and did not provide treatment and care in accordance with professional standards of practice after a fall with head injury and subsequent change in condition.
Failure to Implement Elopement Precautions and Supervision for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and implement elopement precautions for a cognitively impaired resident who was identified as being at risk for elopement. The resident was admitted with multiple neurological and substance-related diagnoses, including cerebral infarction, ataxia, Wernicke’s encephalopathy, alcohol and opioid dependence, and traumatic subdural hemorrhage. On admission, the resident’s elopement risk screening showed a score of 12, indicating elopement risk, and nursing documentation described poor safety awareness, poor judgment, and a need for continuous cues with self-care and ADLs. The resident was also noted to require 1:1 supervision during meals due to quick eating behavior. In the hours leading up to the elopement, nursing staff observed the resident wandering in the hallway and behind the nurse’s station and reported that he required constant redirection. The night shift RN informed the day shift LPN during report that the resident had been wandering since early morning and that a WanderGuard was recommended. Despite this, no WanderGuard was applied before the resident left the building. The LPN later stated that she did not know where to obtain a WanderGuard, and the DON confirmed that both the RN and LPN had not placed a WanderGuard because they did not know its location. On the day of the incident, the resident went to the kitchen and requested water, and kitchen staff noticed a fall risk bracelet on his wrist. After this interaction, staff discovered that the resident was no longer in the building. Facility investigation determined that the resident exited through the front door at approximately 9:37 AM and was later found off premises, about one mile away, walking on a sidewalk near a restaurant. A medication technician, who had previously seen the resident wandering in only a gown and had informed the nurse, located the resident and returned him to the facility. These events demonstrate that, despite known elopement risk and observed wandering behavior, the facility did not implement timely elopement precautions or ensure adequate supervision to prevent the resident from eloping.
Failure to Ensure Adequate Supervision and Assistance During Bed Mobility
Penalty
Summary
A deficiency occurred when a resident, who had significant medical conditions including chronic respiratory failure, COPD, high BMI, and diabetes, sustained a fall from bed during incontinence care. The resident was identified in the most recent Minimum Data Set (MDS) assessment as requiring extensive assistance from two or more persons for bed mobility. However, at the time of the incident, only one Certified Nursing Assistant (CNA) was providing care, and the resident was rolled to her side for a brief change, resulting in her falling from the bed. The care plan and documentation regarding the required level of assistance for the resident were inconsistent and unclear. Interviews with staff revealed confusion about whether the resident required a one-person or two-person assist for bed mobility and brief changes. Some CNAs reported that the resident was often changed by one person, sometimes by two, and that the resident herself sometimes requested only one CNA. The MDS Coordinator confirmed that the resident's last quarterly assessment indicated a need for two-person assistance, but this was not consistently reflected in the care plan or communicated to all staff. The Director of Nursing (DON) acknowledged that prior to the fall, the resident's assistance status was not listed in the KARDEX or care plan, and staff relied on informal sources such as the "CNA Bible" or verbal communication to determine assistance needs. At the time of the fall, the resident's bed was in an elevated position, which was her preference, and she was on an air pressure mattress (APM) that was in alternating mode. The CNA providing care stated she had performed one-person brief changes for this resident multiple times without issue until the incident. The lack of clear, updated documentation and communication regarding the resident's assistance needs, combined with the use of only one staff member for a resident assessed as needing two-person assistance, directly led to the fall and resulting injuries, which included multiple fractures and a head laceration.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
A deficiency occurred when a resident with a history of atrial fibrillation, COPD, and emphysema was allowed to self-administer multiple inhalers without a documented assessment to determine if self-administration was clinically appropriate. The resident was observed to have four inhalers at her bedside, including Arnuity, Spiriva, Albuterol, and Fluticasone, which she obtained from her purse. The resident reported self-administering these medications and keeping the Albuterol inhaler at bedside for emergencies. She also expressed concerns about side effects from one of the inhalers and had refused doses of Arnuity on several occasions. Review of the resident's medical record revealed no documentation of a self-administration of medications assessment, despite the facility's policy requiring an interdisciplinary team evaluation to determine if self-administration was safe and appropriate. Interviews with nursing staff and the DON confirmed that no such assessment had been conducted after admission, even though the resident was provided inhalers at bedside and was self-administering them. The DON stated that the resident was asked about self-administration upon admission and declined, but no further assessments were performed when the situation changed. The facility's policy outlined specific criteria for evaluating a resident's ability to self-administer medications, including physical and cognitive abilities, understanding of medication instructions, and safe storage. However, these procedures were not followed in this case, as the resident was not reassessed for self-administration capability when she began keeping and using inhalers at her bedside. Staff interviews indicated a lack of awareness and oversight regarding the resident's possession and use of multiple inhalers.
Failure to Complete Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess a resident within 14 days after a significant change in condition, specifically following the initiation of hospice services. The resident, who had a diagnosis including cervical disc degeneration, was admitted to hospice care as documented by a physician's order and completed hospice admission paperwork. Despite the initiation of hospice and changes to the resident's medications, there was no Significant Change Minimum Data Set (MDS) assessment completed within the required timeframe. Interviews with MDS Coordinators confirmed that a significant change MDS assessment should have been completed when hospice was started, but this was not done for the resident in question.
Unattended Medication Administration and Lack of Supervision
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical conditions, including heart failure, end stage renal disease, and hypertension, was found with a cup containing 13 pills left unattended at her bedside. The medications were intended for her morning dose, but the licensed nurse who administered them did not remain to supervise their consumption or verify that they were taken in a timely manner. The resident confirmed that the pills were her morning medications, and the state licensor was unable to determine the exact number of pills as they were not removed from the cup for counting. Review of the resident's Medication Administration Record showed that several medications, including blood pressure medications, anticoagulants, supplements, and pain medication, were documented as administered that morning by a registered nurse. The resident's care plan included interventions to administer medications as prescribed and monitor for side effects, particularly due to her risk for complications from anticoagulant and psychotropic medication use. Interviews with nursing staff and the Director of Nursing confirmed that the facility's standard practice was for the licensed nurse to observe residents taking their medications, especially for this resident who was known to doze off and forget to take her pills. It was also noted that some medications, such as Tylenol and Lanthanum Carbonate, were scheduled at specific times and could pose risks if not administered as directed. The Director of Nursing acknowledged that medication should not be left at the bedside unattended and that the nurse should have stayed to observe the resident taking the medication. The DON also stated that the timing of medication administration was important, particularly for medications with flex time ranges, and that leaving medication at the bedside made it difficult to determine when the resident actually took them. The facility did not provide specific education to nurses on this expectation, but it was considered a standard taught in nursing school. Reference materials cited in the report emphasized the importance of adhering to the rights of medication administration and timely delivery of scheduled medications.
Failure to File Laboratory Results in Resident Record
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical record for one resident. Specifically, a resident with multiple diagnoses, including bilateral primary osteoarthritis of the knee, type 1 diabetes mellitus with diabetic polyneuropathy, anxiety disorder, and mood disorder, was admitted and later readmitted to the facility. On a specified date, a physician's assistant ordered a vaginal culture for yeast, trichomonas vaginalis, and sexually transmitted diseases due to a diagnosis of vaginal discharge. Although the order was completed, the laboratory results were not found in the resident's electronic medical record during a review. Interviews with facility staff confirmed that the lab results, which were from an outside facility, had not been requested or uploaded to the resident's record.
Failure to Accurately Document Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was prescribed narcotic pain medication. Specifically, the resident, who had diagnoses including cervical disc degeneration, bilateral primary osteoarthritis of the knee, and chronic pain syndrome, was observed to be in pain and requested pain relief. The resident had a physician's order for Morphine Sulfate Solution to be administered as needed for pain. Upon review, it was found that although the Narcotic Record Book documented administration of Morphine on multiple occasions, these administrations were not signed out as given on the Medication Administration Record (MAR). Interviews with staff confirmed that the resident received pain medications, and the narcotic record indicated doses were given. However, both the LPN and the Unit Manager acknowledged that the administration of Morphine was not documented on the MAR as required. The failure to sign out the medication on the MAR resulted in incomplete and inaccurate medical records for the resident.
Medication Errors Affect Multiple Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting 7 out of 14 sampled residents. One resident received another resident's medications, including Xanax, Eliquis, Norco, Lyrica, and Zoloft, which led to a hospital admission for sinus bradycardia and required continuous heart monitoring. The Director of Nursing acknowledged the error, which was documented in an incident report. Another resident did not receive medications according to physician orders, receiving incorrect dosages of Oxycodone and Pantoprazole. The resident was given 10 mg of Oxycodone instead of the prescribed 5 mg and 40 mg of Pantoprazole instead of 20 mg. The errors were acknowledged by the facility's Director of Nursing, and the discrepancies were noted in the resident's medical records and progress notes. Additional errors included a resident receiving a medication to which they had a known allergic reaction, and two residents receiving incorrect medications. One resident was given short-acting insulin instead of long-acting insulin, and another received a different patient's medications, including insulin, which they did not take. These errors were documented in progress notes and incident reports, and the Director of Nursing acknowledged the failures in medication administration.
Incomplete Investigation of Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident who fell and sustained injuries. The resident, who had a history of polyneuropathy, chronic respiratory failure, dementia, restless leg syndrome, and type 2 diabetes mellitus, was found on the floor with a large bump on the forehead, blood on the nose, and numbness in the right arm and hand. The incident occurred when a CNA left the resident unattended during a brief change to retrieve a new sheet, and upon returning, found the resident on the floor. The investigation into the incident was incomplete, as it lacked interviews with key staff members and the resident involved. The facility's final investigation form did not include interviews with the nurse or unit manager, and there was no documentation regarding the duration the CNA was absent or the positioning of the resident's bed. The CNA reported that the resident had a tendency to act independently and had rolled out of bed to retrieve a stuffed dog from the floor. The Social Service Workers involved in the investigation acknowledged that they relied on existing progress notes instead of conducting thorough interviews with all relevant parties. The investigation concluded that the allegation of neglect was not verified, despite the lack of comprehensive evidence collection. This deficiency highlights the facility's failure to conduct a complete and thorough investigation into the alleged neglect, as required by regulatory standards.
Inadequate Supervision and Equipment Failure During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistance devices for a resident, leading to an incident where the resident was manually lifted by two staff members instead of using a Hoyer lift. This resulted in an assisted fall to the ground. The resident, who had a history of repeated falls and required a Hoyer lift for transfers, experienced a pop in her right shoulder during the manual transfer, causing her pain. The resident, identified as cognitively intact, had a care plan that included interventions to prevent falls, such as staff education on safe transfer techniques and keeping the room free of clutter. However, during the incident, the Hoyer lift ran out of batteries, prompting the staff to attempt a manual transfer. The resident reported shoulder pain and was sent to the emergency department, where X-rays showed no acute fracture but a likely rotator cuff injury. Interviews with the staff involved revealed that the Hoyer lift was not properly charged, leading to its failure during the transfer. The staff attempted to manually lift the resident, unaware of her shoulder issues, which resulted in the resident experiencing pain. The facility's investigation documented that the resident did not sustain any major injury, but the incident highlighted a lapse in following the care plan and ensuring the availability of functional equipment for safe transfers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tooele
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Copper Ridge Health Care | 16.9 mi | — | 3 | 0 |
| Meadow Peak Rehabilitation | 17.2 mi | — | 0 | 0 |
| Rocky Mountain Care - Riverton | 17.6 mi | — | 0 | 0 |
| Legacy Village Rehabilitation | 18.3 mi | — | 2 | 0 |
| Rocky Mountain Care - Hunter Hollow | 18.7 mi | — | 19 | 0 |
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