Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Intermountain Health Holy Rosary Hospital during CMS and state inspections, most recent first.
Medical director participation in the QA program was not maintained at least quarterly. Staff stated the medical director was onsite about monthly but did not always attend scheduled QA meetings in person or by teleconference, and he had no authorized designee to attend for him. The QAPI attendance roster did not show his participation, and there was no documentation that QA content was communicated to him for acknowledgment. His service agreement also included responsibilities for clinical quality control programs and protocols.
Failure to Provide Required Effective Communication Training: The facility did not provide required effective communication training to all direct care staff. An interview confirmed the last all-staff training covering effective communication was completed previously, and the facility stated annual training was expected at hire and thereafter. Record review showed the last training on effective communication had been provided, and the facility did not produce the requested policy or procedure for staff education and training requirements by the end of the survey.
Failure to Provide Required Dementia Training: The facility did not provide required all-staff dementia training, including management of dementia-related behaviors. Staff reported that the last dementia training was completed about two years ago and that no further dementia education had been provided since then. Record review confirmed the last all-staff dementia care training on file, and the facility did not produce a policy for dementia training requirements by the end of the survey.
The facility failed to submit required investigation findings to the State Survey Agency (SSA) within 5 working days for multiple abuse and elopement incidents. In one case, a resident kicked another resident’s feet, and in another, one resident kicked another in the legs while both were in wheelchairs; in both situations, the facility did not provide timely or, in one case, any investigative findings to the SSA. The facility also reported two separate elopement events for a resident but did not submit final investigation reports for either incident. A staff member reported that another staff member, who was absent during the survey, was responsible for SSA reporting, and confirmed the expectation to report all investigation results within 5 working days per facility policy.
Two residents were involved in a resident-to-resident abuse incident in which one resident kicked another multiple times while both were in wheelchairs, and although staff separated them and documented the event, the facility did not complete or document a formal abuse investigation, did not ensure ongoing protection from further confrontations, and did not report investigative findings to the SSA. In addition, several residents experienced multiple elopements, with documentation that one resident followed others out back doors and another exited through doors into a hospital area, yet the facility’s investigation files lacked clear timelines, comprehensive staff interviews, identification of information sources, and root-cause analyses of exit-seeking behavior. Staff interviews confirmed that while nurses submitted occurrence reports and SSA notifications and discussed root causes informally, management did not consistently document thorough investigations or root-cause findings as required by facility policy.
The facility failed to provide adequate supervision and effective elopement-prevention interventions for several cognitively impaired, exit-seeking residents who were known elopement risks. Despite assessments, care plans, anti-wandering devices, and door alarms, residents repeatedly exited through front and back doors without timely staff redirection or alarm response, and some elopements were not properly documented in the EHR. One resident with dementia and short-term memory loss was not care planned for elopement until after multiple attempts, and another resident with severe cognitive impairment left through sliding doors unnoticed. A resident with an anti-elopement alarm on her wheelchair repeatedly triggered the door alarm throughout the day, yet staff did not effectively respond, allowing her to exit unsupervised and fall on stairs, sustaining minor injuries.
A resident’s grievance about personal care was not effectively resolved or documented. The resident and family said CNAs continued to provide a milk-based supplement despite requests to avoid milk because of a hiatal hernia and worsening phlegm, mucus, congestion, and cough. Staff acknowledged receiving a family letter of concern and discussing it with the family, but the grievance file was incomplete and no documentation of the outcome or follow-up could be produced.
Pain management was not provided as ordered for a resident with chronic pain syndrome and severe, near-constant pain. A scheduled hydrocodone-acetaminophen order was held multiple times, and only one pain assessment documented severe pain while no other assessments were completed on the dates the doses were missed. Staff gave conflicting statements about pain assessment expectations and could not explain why the medication was held.
The facility did not maintain a consistent antibiotic stewardship program, as infection surveillance and mapping were not conducted and infection tracking tools were incomplete for an extended period. A staff member responsible for infection control was unable to identify infection trends and had not completed required tracking, citing inexperience in the role.
The facility failed to prevent elopement and secure hazardous tools, leading to a resident eloping into a hospital due to an unactivated alarm. Staff were not consistently aware of residents at risk for elopement, and the facility lacked an elopement assessment. Additionally, unsecured tools in the activity room posed a risk to residents, with staff unsure of how to maintain tool safety.
The facility did not provide COVID-19 vaccinations to three residents who either requested or were waiting for the vaccine, and failed to document staff education and declinations for two staff members. Interviews revealed the vaccine was not kept on site due to cost and waste concerns, and the facility's policy did not address staff vaccination requirements.
The facility did not provide required education or obtain informed consent from residents or their representatives regarding the risks and benefits of psychotropic medications, as evidenced by three residents receiving such medications without documentation of education or consent in their medical records. Staff confirmed that consent was expected but could not produce the necessary documentation when requested.
A resident was provided with bed rail assist bars without a documented review of risks and benefits or obtaining informed consent. The resident did not request the rails and was able to move and sit up independently. Staff confirmed that no consents were obtained for any residents using grab bars, and the evaluation form did not include a safety assessment or address entrapment risk related to the resident's physical ability or low weight.
The facility failed to update care plans with interventions to prevent falls for three residents. One resident experienced a hip fracture after a fall, but the care plan was not updated with new interventions. Another resident had multiple falls, yet the care plan had not been updated since April. A third resident fell from a Broda chair, and although contributing factors were identified, the care plan was not updated. Care plans were only updated weekly, and challenges were noted due to interim agency nurses.
Medical Director Did Not Attend QA Meetings
Penalty
Summary
The facility failed to ensure that the medical director or his designee attended and participated in the Quality Assurance (QA) program at least quarterly. During an interview, staff member A stated that staff member G was onsite about once a month, but his visits did not always coincide with scheduled QA meetings. Staff member A also stated that staff member G was not currently attending QA meetings quarterly, either in person or by videoconference or teleconference, and did not have an authorized designee to attend in his place. She further stated that she reviewed QA minutes with staff member G but did not have documentation showing his acknowledgment of the information provided. Review of the QAPI agenda and attendance roster from 9/9/25 through 4/24/26 did not show staff member G as an attendee. There was no evidence that staff member G had a designee for the QA meetings or that a non-required committee member communicated the meeting content to him for acknowledgment. During an interview, staff member G stated he had not been attending the QA meetings in person or electronically and did not have a designated proxy to attend in his absence, and he acknowledged that attendance at the QA meetings was expected in his role. Review of his Professional Service Agreement, signed 10/25/24, showed that the contractor, through the Medical Director, was to provide clinical quality control programs and protocols meeting legal requirements.
Failure to Provide Required Effective Communication Training
Penalty
Summary
The facility failed to provide required effective communication training to all direct care staff members. During an interview, staff member A stated the last all-staff training that included effective communication was provided on 8/29/24, and that the next annual training was due on 8/29/25. Staff member A also stated the facility had established a training program that included effective communication but failed to implement it by the due date, and that the expectation was for all direct care staff to receive this training at hire and annually thereafter. Review of the facility’s all-staff training records showed the last effective communication training was provided on 8/29/24. When surveyors requested the policy and procedure for staff education and training requirements related to effective communication, the facility did not provide additional documentation by the end of the survey on 4/23/26.
Failure to Provide Required Dementia Training
Penalty
Summary
The facility failed to provide required dementia training to all staff, including training on management of dementia-related behaviors. During interview, staff member A stated the last all-staff dementia training was on 8/29/24 and that the next annual training was due on 8/29/25, but all staff had not received dementia training since that date. Staff member A also stated the facility had established a dementia training program but failed to implement it by the due date, and that the expectation was for all staff to receive dementia training at hire and annually thereafter. Staff member V stated the facility used quarterly Workday assignments for training and did not remember doing any specific dementia training. Staff member X stated she had dementia training about two years ago and that no dementia training had been done since then. Record review showed the last all-staff dementia care training was provided on 8/29/24, and the facility did not provide a policy or procedure for staff education and training requirements for dementia care by the end of the survey.
Failure to Submit Abuse and Elopement Investigation Findings Within Required Timeframe
Penalty
Summary
The facility failed to submit investigation findings related to alleged abuse and elopement incidents to the State Survey Agency (SSA) within the required 5 working days for multiple residents. For one incident dated 1/24/26, a resident left her room and kicked another resident’s feet; the facility’s investigative findings for this event were not submitted to the SSA until 2/4/26, which was 11 days after the incident was reported. For another incident dated 3/20/26, one resident kicked another resident in the legs while both were in wheelchairs, with no injuries reported and immediate separation of the residents; review of records showed no evidence that the facility ever submitted investigative findings for this incident to the SSA. Additionally, review of the SSA reporting site showed that the facility made initial reports of elopement for a resident on 7/18/25 and 2/1/26 but did not submit final investigation reports within the required 5 working days. There were no final reports for either elopement incident. During an interview, a staff member stated that another staff member, who was out of the facility during the survey week, was responsible for reporting and submitting investigative findings to the SSA for abuse allegations. The same staff member confirmed the expectation that findings of any abuse allegation be reported to the SSA within 5 working days and acknowledged they could not provide investigative findings for the 3/20/26 incident. The facility’s written policy, reviewed and dated 7/15/25, required that results of all investigations of alleged violations be reported within 5 working days of the incident.
Failure to Investigate Resident Abuse and Elopements or Identify Root Causes
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and manage an allegation of resident-to-resident abuse and multiple resident elopements. In one incident, a resident in a wheelchair kicked another resident multiple times in the lower legs while both were at the nurses’ station. Nursing documentation noted the kicking and that there were no injuries, and the immediate response was to separate the residents. However, review of the facility’s abuse investigations for the relevant period showed no completed investigation related to this reported allegation of resident-to-resident abuse, and there was no documentation of investigative findings or that these findings were reported to the State Survey Agency. The facility also failed to protect the involved residents from further potential abuse. Nursing notes for both residents documented that, two days after the kicking incident, one resident was observed continually attempting to follow, communicate with, agitate, and argue with the other resident, and staff had to separate them twice. Staff communicated to others to monitor their interactions, but the notes showed that the residents continued to have problematic contact, indicating that the facility did not prevent further potential abuse between them. During interview, a staff member stated that another staff person was responsible for investigating and reporting abuse allegations, but that person was unavailable and no documentation could be produced to verify that an investigation had been completed or that results were reported to the state agency, despite facility policy requiring thorough investigation, protection of residents during the investigation, and reporting of results. The deficiency also includes failures related to multiple elopements by several residents. For one resident, an elopement investigation documented that the resident exited the facility, but the investigation lacked signatures, identification of information sources, and clear involvement of the email sender included in the file. A state abuse reporting entry indicated that this resident left through back doors, possibly following a volunteer or staff taking other residents to Mass, and was brought back by a Med-Surg nurse, but there was no documented root-cause analysis or explanation of why the elopement occurred or what interventions were implemented to prevent recurrence. Another resident eloped through doors leading into the hospital; the reportable incident was submitted to the SSA, but there were no nurses’ notes on the date of the elopement describing the event, and a note the following day only stated that the resident attempted to elope twice, reflecting incomplete contemporaneous documentation. For this same resident, the facility’s investigation of the elopement included only limited staff interviews and did not include interviews with CNAs or activity staff to establish a full timeline of the resident’s movements or to identify the root cause. A subsequent elopement by this resident into the hospital was documented in a nursing note, and the investigation consisted of an undated handwritten note stating that people came into the unit looking for someone in the hospital, left to go to Med-Surg, and the resident followed them out the door, with the door alarm functioning and the resident returning to the unit. There was no documented timeline, no detailed interviews, and no analysis of the effectiveness of elopement-prevention interventions. A third resident had multiple documented elopements over several months, with investigation files that often contained only brief summaries, incomplete checklists, or limited supporting documents such as bounds reports or invoices for a wander guard system. Across these events, the facility did not consistently document root-cause analyses or assessments of the resident’s exit-seeking behavior, and the record notes that this failure to identify and document root causes led to a fall with injury for this resident. Interviews with staff confirmed that the facility’s practice did not align with its stated expectations. One staff member reported that a former staff person had previously conducted incident investigations but had left months earlier, and that the expectation for investigations was to determine the root cause of incidents and monitor residents to ensure interventions were implemented. Another staff member stated that after each elopement, the nurse would file a report to the SSA and update the care plan, after which management was supposed to conduct a full investigation. A further interview indicated that nurses entered occurrence reports and submitted SSA reports to track elopements and that staff discussed root causes but did not maintain documentation of those analyses. These statements, combined with the incomplete and inconsistent investigation records, demonstrate that the facility did not carry out or document thorough investigations, root-cause analyses, or protective measures as required by its own abuse investigation and reporting policy.
Failure to Prevent Elopements and Respond to Anti-Wandering Alarms
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective interventions to prevent elopements for multiple residents identified as at risk for wandering, despite existing assessments and care plans. Staff reported that residents at risk for elopement were identified by the MDS nurse on admission and quarterly, and that anti-wandering devices and door alarms were in place, particularly at the front door. However, staff also indicated that wander guard bracelets could be applied without formal assessment, and that information about elopement risk was communicated via paper “brain” sheets. The facility had a written SBAR and procedure for anti-wandering door alarms, including immediate resident location checks and following an elopement procedure, but the report shows these processes were not effectively implemented. One resident with a documented elopement risk and dementia was care planned to have an anti-wander device on her wheelchair and to be involved in activities and redirected when she attempted to exit. She eloped on at least two occasions: once when she went through the first set of doors and was found in a corridor by another resident, and another time when she exited through back doors, apparently following others going to Mass, with no alarms triggered. Her care plan documentation was inaccurate regarding the presence of a wander guard door in 2024, and there was no nursing documentation of the February elopement in her electronic health record. Another resident with severe cognitive impairment (BIMS score of 3) and an elopement risk care plan that included redirection, diversional activities, and ensuring door alarms were activated, was able to get out between the sliding front doors when someone was entering or exiting, and no one saw her leave, contrary to the care plan interventions. A further resident with dementia and short-term memory problems was identified as at risk for elopement, yet his elopement care plan and interventions were not initiated until after he had already eloped twice in one afternoon through different doors. He later eloped again, but the corresponding nursing note was not provided. Another resident, described as exit seeking and very independent with behavioral issues toward staff, had an anti-elopement alarm device on her wheelchair that sounded as she approached the door and had been near the door setting off the alarm throughout the day. Despite this, she was able to push open the main entrance sliding doors, exit, and then fall while attempting to walk down stairs, sustaining an abrasion and bruising and requiring hospital evaluation. Staff interviews indicated that interventions such as 1:1 monitoring, taking her outside, and diversional tasks were used, and that elopements were tracked via occurrence reports and state submissions, but the facility failed to identify the need for continuous one-on-one monitoring for this resident, failed to respond appropriately to the anti-elopement door alarm, and failed to prevent her unsupervised exit and subsequent fall. Activity staff also reported that, after a staffing reduction, there were no organized activities after 5 p.m., despite prior recognition that increased monitoring and activities during late afternoon hours were needed for an elopement-risk resident.
Grievance Process Not Followed for Resident Care Concern
Penalty
Summary
The facility failed to ensure a comprehensive grievance process was operationalized and followed effectively for a grievance related to personal resident care for resident #5. During interview and observation, resident #5 and NF3 stated that resident #5 had concerns about care received from CNAs, including receiving a milk-based supplement despite the resident and family asking that milk-based supplements not be given. NF3 reported that resident #5 had a hiatal hernia aggravated by milk, and that the milk-based supplement caused more phlegm and mucus, increased congestion, and worsened coughing. At the time of observation, resident #5’s lunch tray included a large glass of milk-based supplement, and NF3 stated the grievance had not been resolved to the satisfaction of the resident or family. Staff member A acknowledged awareness of a family letter of concern and said it was given to staff member B to address, but she did not place a copy of the letter in the grievance file provided to surveyors. Staff member A also stated that staff member B spent time with the family working through the concerns, but no documentation could be provided to show the outcome. Later, staff member A said resident #5’s grievance was in staff member B’s file and that neither the grievance form nor the follow-up could be accessed. The facility grievance policy stated that complaints and grievances should receive prompt efforts toward resolution, with acknowledgement and active working toward resolution, generally within 7 working days and ongoing progress updates as needed.
Pain Medication Held Without Routine Pain Assessment
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services was not ensured for one sampled resident with chronic pain syndrome. Resident #3’s quarterly MDS indicated pain was present almost constantly, frequently affected sleep, and was severe. The physician ordered hydrocodone-acetaminophen 5-325 mg, 1 tablet three times daily with food, starting 4/9/26, but the MAR showed multiple doses were held and not given on 4/14/26 through 4/17/26. The record showed only one pain assessment on 4/16/26 documenting current pain with a score of 7 out of 10 and ongoing pain, followed by a later reassessment that noted the resident was sleeping. No other pain assessments were completed for the dates when the scheduled pain medication doses were not given. During interviews, the resident stated she usually received her pain medication as prescribed except when staff were too busy. Staff gave conflicting statements about whether pain assessments were required for residents on scheduled pain medication and could not identify why the medication had been held.
Failure to Implement Consistent Antibiotic Stewardship and Infection Surveillance
Penalty
Summary
The facility failed to implement a consistent antibiotic stewardship program, as evidenced by the lack of infection surveillance and mapping to identify trends in infection locations. During an interview, a staff member reported that infections and antibiotic use were not tracked for a specific month, and that the McGreers criteria for tracking infections was not completed during that time. Review of the Infection Control binder revealed an absence of infection mapping and line listings for the entire previous year. The staff member responsible for infection control, who had recently started in her role, was unable to identify any infection trends and was still learning the necessary procedures.
Failure to Prevent Elopement and Secure Hazardous Tools
Penalty
Summary
The facility failed to maintain a safe environment, free from elopements, for several residents. Resident #24 eloped from the Residential Living side of the facility into the hospital due to an unactivated alarm on the dining room doors leading to the hospital. Staff were aware of the need to ensure the alarm was set but no system was in place to monitor its status. Additionally, the facility lacked an elopement assessment for residents in the Residential Living area, and staff were not consistently aware of which residents were at risk for elopement. Staff interviews revealed inconsistencies in identifying residents at risk, with some staff members unable to identify any at-risk residents, while others identified different residents as being at risk. The facility also failed to provide an environment free from accidents and hazards, as evidenced by unsecured tools in the activity room. Observations showed a workbench with various tools, including a double-edged wood saw and other potentially dangerous items, accessible to residents. The activity room was not locked, and the tools were not secured, posing a risk to residents. Staff interviews indicated a lack of awareness and procedures to ensure the safety of these tools, with some staff unsure of how the safety of the tools was maintained. Resident #42, who was near the workbench, expressed concern about the potential danger of the tools.
Failure to Provide and Document COVID-19 Vaccination for Residents and Staff
Penalty
Summary
The facility failed to provide COVID-19 vaccinations to three of fourteen sampled residents, despite documented requests and ongoing need. One resident had specifically requested the Moderna COVID-19 vaccine, but there was no evidence in the electronic health record that the vaccine was administered. Two other residents were documented as waiting to receive the vaccine, with the infection preventionist reportedly working on obtaining it. Staff interviews revealed that the facility did not have the vaccine on hand due to cost concerns and previous issues with waste, and that arrangements to obtain the vaccine from outside sources were not consistently made. Additionally, the facility did not provide education regarding the COVID-19 vaccine to staff, nor did it document staff consent or declination for the vaccine. Requested documentation for two sampled staff members regarding vaccine education and declination was not available. The facility's vaccination administration policy did not address staff requirements for COVID-19 vaccinations, contributing to the lack of documentation and education for staff members.
Failure to Provide Education and Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to provide education and information to residents or their responsible parties regarding the risks and benefits of psychotropic medications, and did not obtain or document informed consent for their use. Specifically, three residents were identified as receiving psychotropic medications—sertraline, citalopram, and trazodone—without evidence in their medical records that they or their representatives were educated about the medications or had given informed consent. For one resident, there was no diagnosis associated with the psychotropic medication order, and for the other two, while diagnoses were present, there was still no documentation of education or consent. Interviews with staff confirmed that consents were supposed to be obtained for all psychotropic medications, indicating an expectation for this process within the facility. However, when written consents were requested for the identified residents, none were provided by the end of the survey period. This lack of documentation and education was observed through record review and confirmed by staff interview.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to review the risks and benefits of using a transfer rail attached to the bed and did not obtain informed consent prior to its installation for one resident. The resident reported that she did not request the bed rail assist bars and that one was already present when she arrived, with another added later. During observation, the resident was able to turn and sit up in bed independently without using the grab bars and maintained an unassisted upright position throughout the interview. The resident also expressed uncertainty about the purpose of the grab bars and indicated she had not been involved in the decision to have them installed. A review of the resident's initial Bed Rail/Assist Bar Evaluation indicated the rails were intended for positioning, bed mobility, and security, but did not include a safety assessment of the resident's physical ability, strength, or size. Staff confirmed that no consents were obtained for the grab bars for this or any other resident, and stated that the evaluation form was used to determine appropriateness and resident desire for grab bars. However, the evaluation did not address entrapment risk related to the resident's physical ability or her underweight status.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to identify root causes for falls and update care plans with interventions to prevent falls for three residents. Resident #3 experienced an unwitnessed fall resulting in a hip fracture, yet the care plan was not updated with new interventions following the incident. Staff member C indicated that care plans were only updated during weekly fall meetings, and there was uncertainty about when specific updates were made. Resident #3's fall was attributed to getting feet tangled in blankets, but the care plan update regarding this risk was not clearly documented. Resident #271 experienced multiple falls, including falling out of a wheelchair and onto his knees during therapy sessions. Despite these incidents, the care plan had not been updated since April, failing to address the root causes of the recent falls. Resident #109 fell out of a Broda chair and was assessed in the emergency room. Although factors contributing to the fall were identified in a post-fall huddle, the care plan was not updated with these interventions. Staff member B noted challenges in maintaining the fall system due to interim agency nurses, with care plans being updated only once a week during team meetings.
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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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