Rocky Mountain Care - Riverton
3419 West 12600 South, Riverton, UT 84065 · Non profit - Corporation · 40 certified beds · (801) 693-3900 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- a middle-of-the-pack inspection score (3/5)
- it has 1 actual-harm citation
- a high number of inspection citations overall (17) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $30,038 in federal fines (most recent 2024-02-20)
- its facility-reported quality-measure score sits well above its independent inspection score
- its payroll-based staffing rating is low (2/5)
- about 19% of its spending goes to commonly-owned related companies
- its last standard health inspection was over 2 years ago — the star rating may not reflect current conditions
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.1% | 0.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 96.9% | 91.0% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.6% | 16.5% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 6.8% | 11.6% | 12.0% | better |
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
73.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 165 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 80.7% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 57 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 1.03 therapist hours per resident per day in 2026Q1 — more than 97% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 73.0%CMS range 66.1–77.8 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 7.5–14.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 80.7% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 80.7% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 86.0% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 97.9% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.8%CMS range 3.3–9.5 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.86 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 40 beds and averages 37.5 residents a day — about 94% occupied, or roughly 2 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.02 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.71 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.78 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.41 hrs/resident/day on weekends vs 4.27 on weekdays — 20% thinner on weekends — a notable drop. RN hours go from 1.84 to 1.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 54% is about the same as the national median of 45%. 3 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
This trend is not current. The most recent of these two inspections was over 2 years ago; the arrow describes what inspectors found then, not what the home is like now.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
17 citations, most serious first. The 11 most serious are shown; the remaining 6 are one tap away and print in full.
- Actual harm · G2021-08-19 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 22 sample residents, that the facility did not ensure each resident was free of significant medication errors. Specifically, a resident with a known allergy was administered a medication she was allergic to and required Narcan. This finding resulted in a harm level deficiency. In addition, another resident that required medication with food was not administered medication with food. Resident identifiers: 28 and 195. Findings include: HARM 1. Resident 195 was admitted to the facility on [DATE] with diagnoses which included after care following joint replacement surgery, morbid obesity, hypertension, hyperlipidemia, and encounter for prophylactic measures. On 8/16/21 at 12:00 PM, an interview was conducted with resident 195. Resident 195 stated that facility staff over medicated and dehydrated her. Resident 195 stated that she was given pain medication that she was allergic to and had to go to the emergency room (ER) at the local hospital. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-09-26 · tag F0801 — widespreadEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of nutrition services. Specifically, the facility did not employ a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of nutrition services. Findings included: On 9/23/24 at 8:51 AM, an initial walk-through of the kitchen was completed. An interview was conducted with the DM who stated she had not completed the training required to serve as the DM. The DM stated she was ServeSafe certified and had taken the RD consulting company's menu training. The DM stated the RD came to the facility every Wednesday, and was available by phone if she had questions or concerns. The DM stated the RD conducted a kitchen audit every week when she was in the facility, but she did not receive the information from those audits. On 9/25/24 at 10:11 AM, an interview was conducted with the RD. The RD stated that she had worked for the facility for two years and was full…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-09-26 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the dish machine was not running properly to sanitize the dishes after meals. Findings included: On 9/23/24 at 8:51 AM, an initial walk-through of the kitchen was conducted. On 9/23/24 at 9:17 AM, an observation was made of the dish machine. The Dietary Manager (DM) was running dishes through the dish machine, three racks had gone through the machine, and were on the belt. A fourth rack was inside the dish machine. The wash cycle was running at a temperature of 160 degrees Fahrenheit. After the wash cycle finished, no water entered the dish machine for a rinse cycle. A container of dish machine detergent was noted to be connected to the dish machine. When questioned what it was, the DM stated that it was empty and did not replace it. On 9/23/24 at 9:18 AM, an observation was made of the dish machine temperature log. The temperatures listed the wash temperature, the rinse temperature, and a sanitizer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-09-26 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, for 3 out of 22 sampled residents, staff were not using the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). In addition, a resident with a physician's order for EBP did not have signage posted on their door and PPE was not readily available. Resident identifiers: 21, 84, and 85. Findings included: 1. Resident 21 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, pyogenic arthritis, cellulitis of right lower limb, cellulitis of left lower limb, pressure ulcer of sacral region stage 3, localized edema, infection and inflammatory reaction due to internal right knee prosthesis, chronic kidney disease, protein-calorie…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, for 1 out of 22 sampled residents, a resident had a urinary catheter without a physician's order. Resident identifier: 180. Findings included: Resident 180 was admitted to the facility on [DATE] with diagnoses which included encounter for other orthopedic aftercare, diffuse large B-cell lymphoma, lymph nodes of head, face, and neck, other acute postprocedural pain, cellulitis of right lower limb, muscle weakness, obstructive sleep apnea, fracture of shaft of right fibula, subsequent encounter for closed fracture with routine healing, fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing, heart failure, venous insufficiency, hypothyroidism, hyperlipidemia, dementia, unspecified severity, without behavioral…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-09-26 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicated that the dose should be reduced or discontinued. Specifically, for 1 out of 22 sampled residents, a resident's blood pressure (BP) support medication was administered outside of the physician's ordered parameters. Resident identifier: 21. Findings included: Resident 21 was admitted to the facility on [DATE] with diagnoses which included cellulitis of right lower limb, cellulitis of left lower limb, pressure ulcer of sacral region, localized edema, muscle weakness, infection and inflammatory reaction due to internal right knee prosthesis, chronic kidney disease, protein-calorie malnutrition, essential hypertension, acute on chronic combined systolic (congestive)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-01 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined, the facility did not consult with a resident's physician when there was a change in the resident's status. Specifically, for 1 out of 21 sampled residents, a resident had a blood glucose reading below 60 and the physician was not notified per the physician's order. Resident identifier: 137. Findings included: Resident 137 was admitted on [DATE] with diagnoses that included atrial fibrillation, esophageal obstruction, tinea pedis, history of falling, pain, heart failure, chronic kidney disease, type 2 diabetes, muscle weakness, and hypertension. On 2/27/23 at 12:13 PM, an interview was conducted with resident 137. Resident 137 stated that on 2/26/23, her blood sugar was checked in the morning and was 125. Resident 137 stated she was given her scheduled insulin. Resident 137 stated she started to feel unwell and when her glucose was checked it was 56. Resident 137 stated she was provided a glucagon shot and was given some orange juice through her feeding…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-01 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, for 2 out of 21 sampled residents, residents that were receiving oxygen therapy did not have the oxygen therapy included in their comprehensive care plan. Resident identifiers: 4 and 17. Findings included: 1. Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, intraspinal abscess and granuloma, sepsis, vertebrogenic low back pain, infection and inflammatory reaction due to internal left knee prosthesis, dysphagia, muscle weakness, need for assistance with personal care, repeated falls, cognitive communication deficit, acute respiratory failure with hypoxia, methicillin susceptible staphylococcus aureus infection,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-01 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, it was determined , the facility did not provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene to residents who were unable to carry out activities of daily living. Specifically, for 1 out of 21 sampled residents, a resident did not receive showers or bathing assistance in a timely manner and according to the facility schedule for showers. Resident identifier: 7. Findings included: Resident 7 was admitted on [DATE] with diagnoses that in included myotonic muscular distrophy, major depressive disorder, mild intellectual disabilities, hypomagnesemia, acute upper respiratory infection, and long QT (measurement of the hearts electrical activity) syndrome. On 2/27/23 at 11:29 AM, an interview was conducted with resident 7. Resident 7 stated that sometimes the staff forgot to shower her. Resident 7 stated she did not remember when her last shower was. On 2/27/23, resident 7's medical record was reviewed. Resident 7's annual Minimum Data…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-03-01 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, it was determined, the facility did not ensure that each resident receives necessary respiratory care and services that are in accordance with professional standards of practice. Specifically, for 2 out of 21 sampled residents, oxygen therapy was provided to residents without a physician's order and there was no documentation regarding the oxygen concentrator tubing maintenance. Resident identifiers: 4 and 17. Findings included: 1. Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, intraspinal abscess and granuloma, sepsis, vertebrogenic low back pain, infection and inflammatory reaction due to internal left knee prosthesis, dysphagia, muscle weakness, need for assistance with personal care, repeated falls, cognitive communication deficit, acute respiratory failure with hypoxia, methicillin susceptible staphylococcus aureus infection, Parkinson's disease, essential…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2021-08-19 · tag F0804 — failed to serve food at safe, palatable temperature — patternEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview it was determined, for 5 of 22 sample residents, that the facility did not provide each resident with food and drink that was palatable, attractive, and at a safe and appetizing temperatures. Specifically, residents complained that the food was not palatable and the test tray was not attractive and palatable. Resident identifiers: 5, 17, 25, 28 and 191. Findings include: 1. On 8/16/21 at 1:44 PM, an interview was conducted with resident 5. Resident 5 stated the cook cannot cook vegetables. Resident 5 stated the food was awful and the pasta was overcooked. Resident 5 stated the meatballs were frozen and the spaghetti sauce looked like brown gravy. On 8/19/21 at 1:30 PM, a follow up interview was conducted with resident 5. Resident 5 stated that the sweet potatoes were hard and she could not chew them. Resident 5 stated she did not know what the sauce was on the meat because it had a strange flavor. 2. On 8/16/21 at 1:19 PM, an interview was conducted with resident 28. Resident 28 stated that all the veggies had been mushy and over cooked. Resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 6 citations
- Potential for harm · Ecited before2021-08-19 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards of food service safety. Specifically, the kitchen floor was dirty, cracked and taped in several areas, the floor under the 3 sink wash station was buckling, the wall behind the stove had white splatter on it. Findings include: 1. On 8/16/21 at 7:50 AM, an initial tour of the kitchen was conducted. The following observations were made: a. A drain was broken near the steam table. b. The linoleum on the floor was cracked around another drain by the steam table. c. The linoleum under the 3 sink dishwashing station was buckled and cracked. d. Tape was observed to be covering cracks in the linoleum throughout the kitchen. e. The floor was dirty behind the oven/stove. 2. On 8/18/21 at 9:41 AM, a second observation was made of the kitchen. The following observations were made: a. The floor was observed to be dirty behind the stove. b. There was white splatter observed behind the stove on the wall. c. The floors were observed to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2021-08-19 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record the review, for 3 of 22 sample residents, it was determined that the facility did not establish an effective infection control program to help prevent the development and transmission of communicable diseases and infections. Specifically, staff members were not wearing personal protective equipment (PPE) in resident rooms that required isolation precautions and there was no aerosolizing generating policy and procedures for a resident that used a Continuous Positive Airway Pressure (CPAP) machine. In addition, food was transported through the hall uncovered. Resident identifiers: 5, 199 and 204. Findings include: 1. Resident 199 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy, alcohol dependence, acute kidney failure, alcoholic hepatitis, vitamin deficiency, pruritus, pain, and mood disorder and nicotine dependence. On 8/16/21 at 7:00 AM, an observation was made of resident 199's room. There was signage on the door and a cart…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-08-19 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined, for 1 of 22 sample residents, that the facility did not treat each resident with respect, dignity and care in a manner and in an environment that promoted maintenance or enhancement of his quality of life. Specifically, a resident was sleeping on a mattress with no sheets. Resident identifier: 21. Findings include: Resident 21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included leukemia, malignant neoplasm of prostate, lymphoma, pneumonia and major depressive disorder. On 8/17/21 at 9:46 AM, an observation was made of resident 21. Resident 21 was laying in bed with his feet hanging off the bed. Resident 21 did not have sheets or blankets on his bed. Resident 21 was observed without a shirt and visible from the hallway. On 8/17/21 at 10:04 AM, an observation was made of Registered Nurse (RN) 2 and Certified Nursing Assistant (CNA) 6. RN 2 and CNA 6 were observed to enter resident 21's room. RN 2 was immediately…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-08-19 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 1 of 22 sample residents, that the facility did not coordinate assessment with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of that part. Coordination included referring all level II residents and all residents with newly evident or possible serious mental disorder for level II resident review upon significant change in status assessment. Specifically, a resident did not have all diagnoses check on the PASARR for a level II referral. Resident identifiers: 21. Findings include: Resident 21 was admitted to the facility on [DATE] with diagnoses which included leukemia, lymphoma, pneumonia, major depressive disorder, and Post-traumatic stress disorder (PTSD). Resident 21's medical record was reviewed on 8/18/2021. A form titled Pre-admission Screening Application/Resident Review Identification Screening dated 6/7/21 revealed no diagnoses of major depressive disorder or PTSD. A section titled Serious Mental…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-08-19 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined, for 1 of 22 sample residents, that the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biological's) to meet the needs of each resident. Specifically, a resident did not have diabetic medication for 2 days. Resident identifier: 3. Findings include: 1. Resident 3 was admitted to the facility on [DATE] with diagnoses which included encephalopathy, muscle weakness, type 2 diabetes mellitus, and history of COVID-19. Resident 3's medical record was reviewed on 8/18/21. A physician's order dated 5/9/21 revealed Metformin tablet extended release 24 hr (hours); 750 mg (milligrams); 1 tab (tablet) orally once a day. According to the July 2021 Medication Administration Record (MAR) resident 3 was not administered Metformin on 7/15/21 and 7/16/21. Facility staff documented Drug/Item Unavailable in the reason's section. On 8/17/21 at 9:15…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2021-08-19 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined, for 2 of 22 sample resident, that medical records were not complete, accurately documented, readily accessible and systematically organized. Specifically, a resident that passed away did not have nursing progress note related to the event and another resident did not have dialysis communication forms in the medical record. Resident identifiers: 28 and 40. Findings include: 1. Resident 40 was admitted to the facility on [DATE] with diagnoses which included pericarditis, chronic lymphocytic leukemia of B-cell type not having achieved remission, chronic kidney disease, hyperlipidemia, type 2 diabetes mellitus, and atrial fibrillation. Resident 40's medical record was reviewed on 8/18/21. Resident 40's progress notes dated 7/26/21 revealed resident was having loose stools, nausea, vomiting but was feeling okay earlier in the day. The plan from the doctor was to check laboratory values and provide intravenous fluids. There was a form titled Record of Death in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$30,038 in federal fines across 5 penalties.
- $4,938 — penalty dated 2024-02-20
- $12,534 — penalty dated 2024-01-22
- $3,418 — penalty dated 2024-01-08
- $2,797 — penalty dated 2024-01-02
- $6,351 — penalty dated 2023-12-11
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ROCKY MOUNTAIN CARE — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 3.0 | +1.0 vs chain |
| Health inspection | 3 of 5 | 2.1 | +0.9 vs chain |
| Staffing | 2 of 5 | 2.9 | -0.9 vs chain |
| Quality measures | 5 of 5 | 4.7 | +0.3 vs chain |
The other 9 homes this chain runs (chain average 3.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BEAVER CITY CORPORATION | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 06/01/2017 |
| BANGERTE, NATHAN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 11/01/2025 |
| BANGERTER, EDWARD | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 11/01/2025 |
| BANGERTER, JOHNATHAN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 11/01/2025 |
| BARNEY, JANETT | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2012 |
| BEEMAN, RAYMOND | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/22/2022 |
| BOARDMAN, LAURA | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/22/2022 |
| BROWN, GARY | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2011 |
| DARBY, MEGAN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 11/01/2025 |
| GATHERUM, JASON | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 11/01/2025 |
| HALE, FREDRICK | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/22/2022 |
| HANSEN, KENT | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 11/01/2025 |
| MIKESELL, BRADLEY | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/22/2022 |
| NEVES, COURTNEY | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 11/01/2025 |
| OAKDEN, RICHARD | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2010 |
| OWENS, JON | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 11/01/2025 |
| ROBINSON, MATT | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2019 |
| SAMUELSON, LANCE | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/22/2022 |
| SCHENA, TYLER | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2024 |
| SMITH, VAL | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2019 |
| SNOWBALL, KELLY | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/22/2022 |
| WIDDISON, ALAN | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 09/22/2022 |
| WRIGHT, CRAIG | Individual | MANAGING CONTROL - GOVERNING BODY | — | since 01/01/2019 |
| LANGFORD, SCOTT | Individual | CORPORATE OFFICER | — | since 03/01/2018 |
| MOSS, TYLER | Individual | CORPORATE OFFICER | — | since 03/01/2018 |
| ROCKY MOUNTAIN CARE - RIVERTON | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/01/2017 |
| CORRENTI, KASEY | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 06/06/2025 |
| SMITH, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 05/01/2024 |
| ROCKY MOUNTAIN CARE LLC | Organization | ADP OF THE SNF | — | since 11/25/2025 |
CMS files one row per role, so the 32 rows in the source record cover these 29 parties — each is shown once here with every role it holds. Nothing is omitted.
3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $1.3M paid to related parties — landlords or management companies under common ownership — equal to about 19% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in UT
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Utah Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 465168. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-09-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.