Below average — CMS composite of the measures below.
The next survey window likely opens around January 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 Rocky Mountain Care - Hunter Hollow during CMS and state inspections, most recent first.
A resident with CVA-related dysphagia, dementia, and a mechanical soft diet was observed coughing, gurgling, and expelling food particles while eating and drinking in the dining room without continuous staff supervision. Staff briefly assisted, then left the resident unattended while he continued to cough and drink milk, despite documentation of aspiration risk and prior aspiration-related respiratory illness. Interviews showed staff were unclear about who was responsible for meal supervision and the resident was not on the dining supervision list.
A resident with cerebral palsy, epilepsy, gastrostomy, and dysphagia was ordered continuous tube feeding at 40 mL/hr with water flushes, but observations showed the pump running at 34 mL/hr on multiple occasions. Feeding bags were also incompletely labeled, with missing initials, formula identification, and clear hang times. RN and DON acknowledged the ordered rate and labeling expectations, and the facility policy required enteral nutrition to follow practitioner orders.
A resident with type 2 DM, diabetic neuropathy, and CKD did not receive ordered Tirzepatide on time because the medication was not available from the pharmacy. The MAR showed late administrations and missed doses, and multiple administration notes stated the drug was not given because it was unavailable. RN and DON interviews confirmed the medication was difficult to obtain and that it was not being delivered on time.
A resident with CVA-related dysphagia, aphasia, and dementia was observed coughing, gurgling, and expelling food particles while eating and drinking milk, with staff briefly assisting but not maintaining close supervision throughout the meal. The record showed a physician order for SLP eval/treat as needed, but therapy was not notified when the resident’s swallowing and eating ability worsened. Interviews confirmed the resident had been coughing up food more often, yet no SLP reassessment had been initiated when the change in condition was observed.
A resident with multiple diagnoses, including hemiplegia, dysphagia, acute kidney failure, and CHF, was mistakenly given 50 units of glargine insulin. The chart showed orders for hourly BG monitoring for 24 hours, but only three BG results were found in the record and no other blood sugar logs for that day could be located. The DON, RNC, and MR staff gave conflicting accounts about where the paper BG records were kept and who was responsible for scanning them into the medical record.
A resident with spastic quadriplegic cerebral palsy, epilepsy, gastrostomy, and dysphagia had a G-tube feeding order for Isosource 1.5 CAL at 40 mL/hr with water flushes, but the feeding was repeatedly observed running at 34 mL/hr. The DON stated staff should follow the ordered rate and label the tube feeding, while the ADM said he thought the feeding tube issue had been resolved in QAPI but could not find audits or education and noted QAPI documentation did not consistently reference feeding tubes.
Missing Emergency Call Systems in Common-Area Restrooms: Surveyors observed that 5 common-area public and staff-accessible restrooms used by residents did not have a call light or emergency call system inside. UM stated more independent residents used these restrooms and recalled a past incident where a resident became stuck in a public restroom. The ADM acknowledged the bathrooms were accessible to residents but lacked call lights, and that residents would be unable to call for help if needed.
A resident with multiple sclerosis and paraplegia, who was at high risk for falls and used an air mattress, was not provided with two-person assistance during a brief change. During care, the resident lost control and fell from the bed, resulting in bilateral femur fractures. Staff interviews revealed inconsistent understanding of assistance requirements for residents on air mattresses, and the care plan did not specify two-person assist for bed mobility at the time of the incident.
A CNA did not perform hand hygiene or use required personal protective equipment when caring for a resident under enhanced barrier precautions for a wound. The CNA exited the room, handled potentially contaminated items, and entered another resident's room without sanitizing hands, contrary to facility policy. The DON confirmed that the resident still required these precautions.
Failure to Supervise a Resident With Dysphagia During Meals
Penalty
Summary
The facility failed to ensure that a resident with significant dysphagia was supervised and assisted during meals to keep the resident’s environment as free of accident hazards as possible. The resident had diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, facial weakness, dysarthria, dysphagia, aphasia, muscle weakness, dementia, cognitive communication deficit, contracture of the right knee, and ataxia. The resident’s physician orders included a mechanical soft ground texture diet with thin liquids, and the care plan identified the resident as needing assistance with meals as needed. During observation in the dining room, the resident was seen eating lunch while seated in a wheelchair. He had a productive wet cough while drinking milk and continued coughing after eating mashed potatoes with gravy. Staff member 1 initially sat with him, then left to retrieve a clothing protector and later left the resident’s side to assist another resident, while the resident continued drinking milk and coughing without staff present. Food particles were observed being propelled from his mouth, milk dribbled down his chin, and he was heard gurgling and clearing his throat while attempting to sit himself up using his left arm because his right arm was weak and supported on a board attached to the wheelchair. No staff remained with the resident during this period, and staff member 2 later approached, wiped his mouth, removed the clothing protector, and asked if he was done eating. Staff member 2 then called RN 3 after noting that the resident had a lot of mucus and might be choking on milk or mucus. RN 3 and staff member 2 took the resident to his room. The record review also showed recent provider notes documenting significant post-stroke dysphagia, aspiration risk, aspiration pneumonia, bronchitis likely related to aspiration risk, and that the resident was unable to follow directions for meals and frequently was not sitting up properly during eating. Interviews with staff and leadership indicated that the resident was supposed to be supervised while eating, but he was not on the list for dining supervision, was not being watched by a designated CNA or RNA, and staff were uncertain about speech therapy recommendations and dining supervision processes.
Tube Feeding Infused at Incorrect Rate and Improperly Labeled
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident receiving tube feeding. Resident 90 was admitted with diagnoses including spastic quadriplegic cerebral palsy, epilepsy, gastrostomy, and dysphagia, and was NPO. A physician order directed Isosource 1.5 CAL to be given via G-tube at 40 mL/hr for 22 hours per day with water flushes of 45 mL/hr for 22 hours. During multiple observations, the tube feeding pump was infusing at 34 mL/hr instead of the ordered 40 mL/hr. The feeding bags were also not properly labeled. Observations showed stickers with dates, but no initials, no clear identification of the formula in the bag, and no clear documentation of the time the feeding was hung. A separate bag of fluid was observed with a date only, without indication of what the fluid was, the time it was hung, or initials. RN 1 stated the feeding should have been running at 40 mL/hr and acknowledged the rate was wrong when the order was reviewed. The DON stated staff should follow the prescribed rate and label the feeding with the date, formula/flush, rate, and initials. The facility policy required enteral nutrition to be administered consistent with practitioner orders.
Pharmacy did not supply ordered diabetes medication on time
Penalty
Summary
The facility did not provide routine and emergency drugs and biologicals to meet resident needs. For one sampled resident with type 2 diabetes mellitus with diabetic neuropathy and chronic kidney disease, the ordered Tirzepatide injection for diabetes was not consistently available from the pharmacy for administration. The resident stated he had not received the GLP1 shot that was due three days earlier and said staff told him it was always given late because the pharmacy did not deliver it. Record review showed the resident’s physician order dated 2/9/26 directed Tirzepatide 10 mg subcutaneously at bedtime every Monday for diabetes. The MAR showed the medication was administered late three times between 9/1/25 and 2/11/26 and that doses were missed during the weeks of 1/1/26 and 1/31/26. Administration notes from 9/18/25 through 2/8/26 included multiple entries stating Tirzepatide was not given because it was not available. RN 2 stated the medication was hard to get from the pharmacy because insurance approval was needed and that it should have been administered weekly, usually on Fridays, but the pharmacy did not send it on time. The DON stated nurses needed to contact the pharmacy to order the medication and that residents should be getting medications on time, and if not, nurses should have notified the doctor.
Failure to Notify SLP of Worsening Dysphagia During Meals
Penalty
Summary
The facility failed to provide required specialized rehabilitative services, specifically speech-language pathology, for one resident who had a history of cerebral infarction with hemiplegia, facial weakness, dysarthria, dysphagia, aphasia, dementia, and cognitive communication deficit. The resident had a physician order for speech therapy to evaluate and treat as needed, and the care plan identified him as at risk for nutritional deficits related to stroke and dysphagia, with an intervention to provide assistance with meals as needed. The record also showed prior aspiration-related respiratory issues and notes indicating ongoing dysphagia and aspiration precautions. During lunch, the resident was observed coughing repeatedly while drinking milk and eating a mechanical soft meal. He had a productive wet cough, gurgling, throat clearing, and food particles were seen propelled from his mouth onto his chin and chest. He continued to cough while drinking milk, was observed trying to sit himself up, and no staff remained with him for part of the meal. Staff member 2 later found him gurgling with milk on his face, wiped his mouth, and called the RN after stating she thought he was choking on milk or mucus. The RN and staff member 2 then took the resident to his room, and there was no documentation of the event in the medical record. Record review and interviews showed that speech therapy was not notified when the resident’s eating ability changed. The restorative nursing assistant stated the resident was not on the list for supervision or assistance with eating even though he needed to be watched and had been coughing up food more often. The Director of Rehabilitation stated nursing should have notified therapy of any change in condition so speech therapy could evaluate him, but no one had reported the increased coughing or aspiration pneumonia. The Nurse Practitioner stated she had been notified the prior week that the resident was having increased difficulty eating and spitting out food. The DON stated staff watched for coughing and choking while eating and said speech therapy would reevaluate the resident and update the care plan.
Incomplete blood glucose documentation after insulin medication error
Penalty
Summary
Medical records were not maintained in a complete and systematically organized manner for one resident when blood glucose results were missing from the chart after the resident was mistakenly given 50 units of glargine insulin. Resident 126 was admitted and later readmitted with diagnoses including hemiplegia and hemiparesis of the right dominant side, dysphagia, acute kidney failure, and chronic congestive heart failure. A progress note documented the medication error and that the resident was to have blood glucose monitored every hour for 24 hours, with any blood glucose under 100 reported to the medical provider. The medical record contained blood glucose documentation at 8:35 AM, 11:36 AM, and 2:31 PM on 11/23/25, but no other blood glucose records for that day could be located or were provided by the facility. The DON stated she kept paper blood sugar records in binders in her office and gave copies to medical records to scan, but she was unable to find the log. The DON later stated she remembered writing the blood sugars down and was unsure whether medical records was behind. The RNC stated offsite staff had been helping with scanning documents, while the MR staff stated she scanned items from a box at the nurses' stations, was not caught up, and was unsure where the blood sugar log was located.
Feeding Tube Orders Not Followed and QAPI Monitoring Was Incomplete
Penalty
Summary
The facility did not establish and implement written policies and procedures for feedback, data collection systems, monitoring, and adverse event monitoring related to feeding tubes, and it did not identify the underlying cause of the feeding tube problems or document how corrective actions were monitored. During the previous recertification survey completed on 1/11/24, Federal tag 693 had already been cited at a D level for feeding tube noncompliance, and the Administrator later stated he believed the feeding tube issue had been resolved in QAPI meetings but was not sure. He also stated that in February 2024 there was a QAPI note about compliance for feeding tubes, nursing charting, and life safety, but there was nothing in the March 2024 QAPI that referenced feeding tubes, and he was unable to find any audits or education that had been completed. Resident 90, who had diagnoses including spastic quadriplegic cerebral palsy, epilepsy, gastrostomy, and dysphagia, had a physician order for Isosource 1.5 CAL via G-tube at 40 mL/hr for 22 hours per day with water flushes of 45 mL/hr for 22 hours. The resident’s feeding tube was observed running at 34 mL/hr on 2/9/26 at 8:50 AM, 2/10/26 at 9:28 AM and 2:45 PM, and 2/11/26 at 10:20 AM. The DON stated the staff should always follow the prescribed rate, that the feeding should have been running at 40 mL/hr with 45 mL flushes for 22 hours, and that staff should label the tube feeding with the date, formula/flush, rate of the feeding, rate of flush, and initials.
Missing Emergency Call Systems in Common-Area Restrooms
Penalty
Summary
The facility failed to ensure that an emergency call system was available and accessible in 5 out of 5 public and staff-accessible restrooms located in common areas used by residents. Surveyors observed that the public restroom in the Winder Lane hallway, the public restroom in the [NAME] Blvd hallway adjacent to the conference room, the public restroom near the door labeled About Hair, the staff restroom in the pass-through from the main common area to the Harmon's Way hallway, and the additional public restroom in the [NAME] Blvd hallway near the DON's office all did not have a call light located within. During interview, UM 1 stated that more independent residents would use the public restrooms and recalled a past incident in which a resident became stuck in a public restroom. The ADM stated that these bathrooms were accessible to residents but did not contain call lights, and acknowledged that residents would be unable to call for help if needed. The ADM also stated that corporate ownership had been notified by email about the issue on 12/22/25, but it had not yet been rectified.
Failure to Provide Adequate Supervision During Bed Mobility Results in Resident Fall and Fractures
Penalty
Summary
A resident with multiple sclerosis, paraplegia, a history of falls, and other significant medical conditions was admitted and later readmitted to the facility. The resident was using an air mattress and had bilateral side rails to assist with bed mobility. The care plan specified a two-person assist for transfers but did not include a two-person assist for bed mobility, despite the resident's high risk for falls and use of an air mattress. On the day of the incident, a CNA was providing a brief change for the resident. During the process, the resident rolled to her left side, let go of the positioning bar to grab her catheter, and subsequently lost control, sliding off the bed. The CNA attempted to hold the resident but was unable to prevent the fall, as the resident lost control from her hips down. The resident sustained scratches on her face and was later found to have bilateral femur fractures, requiring hospital admission. Interviews with staff revealed inconsistent understanding of the requirements for two-person assistance for residents on air mattresses. Some CNAs believed that the need for assistance depended on the resident's individual ability, while others relied on shift reports or personal observation. The DON confirmed that the resident should have had a two-person assist for bed mobility due to the air mattress, but this was not reflected in the care plan at the time of the incident.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
A certified nursing assistant (CNA) failed to adhere to the facility's infection prevention and control program by not performing hand hygiene between resident rooms. The CNA was observed exiting a resident's room that was under enhanced barrier precautions, carrying a bag of garbage and a water mug. Despite signage requiring hand hygiene upon entry and exit, as well as the use of gowns and gloves for high-contact care, the CNA did not sanitize or wash hands after discarding the garbage and before entering another resident's room. The CNA also did not wear a gown or gloves while providing care to the resident with a wound, contrary to the posted requirements and facility policy. During interviews, the CNA stated that she believed the enhanced barrier precautions were no longer necessary because the resident's wound had healed, and therefore did not follow the required protocols. The Director of Nursing (DON) confirmed that the resident still had a wound and that staff should have been using gowns and gloves when providing care. Review of the facility's Enhanced Barrier Precaution and Hand Hygiene policies, both updated in April 2025, confirmed that staff are expected to comply with these precautions for residents with wounds and to perform hand hygiene between resident contacts and after handling contaminated objects.
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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 West Valley City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadow Peak Rehabilitation | 1.6 mi | ★★★★★ | 0 | 0 |
| Alpine Meadow Rehabilitation And Nursing | 2.9 mi | ★★★★★ | 0 | 0 |
| Legacy Village Rehabilitation | 3.3 mi | ★★★★★ | 2 | 0 |
| Monument Healthcare Taylorsville | 5 mi | ★★★★★ | 15 | 0 |
| Little Cottonwood Rehabilitation And Nursing | 5.3 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.