Rocky Mountain Care: Accident Hazard Violations - UT
Federal inspectors responding to a complaint found the nursing home failed to properly monitor residents' departures from the building. The violation centered on what administrators called their "LOA book" — a logbook where residents were supposed to record when they left, where they were going, and when they expected to return.
The system broke down entirely.
During the inspection, the Director of Nursing acknowledged the facility was relying heavily on temporary agency staff when "resident 3's incident" occurred. She didn't elaborate on what happened to resident 3, but the timing coincided with the tracking failures that triggered the federal complaint.
The LOA book sat at the nurses' station, according to the director. Residents who were "alert and oriented" typically received permission to leave on their own, she explained. But the process depended on residents voluntarily signing themselves out — a system that clearly wasn't working.
The director blamed the agency staff for not understanding the leave procedures. She told inspectors the temporary workers didn't know how to manage residents who wanted to leave the building. This created gaps in the facility's ability to account for where residents were at any given time.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm," but the breakdown revealed deeper problems with the facility's basic safety protocols. When nursing homes can't track residents' whereabouts, the consequences can be severe — from missed medications to residents becoming lost or injured while away from supervised care.
The inspection report doesn't detail how many residents were affected by the tracking failures or how long the problems persisted. It also doesn't specify what happened during "resident 3's incident" that brought the issue to federal attention.
Rocky Mountain Care's reliance on agency staff created what the director herself acknowledged was a problematic situation. Temporary workers, unfamiliar with facility procedures, were left to manage a system that required consistent enforcement and clear communication with residents.
The LOA book system itself appeared flawed from the start. It required residents to self-report their departures and return times, with no apparent backup verification from staff. When temporary workers didn't understand the process, the entire tracking system collapsed.
The violation occurred under federal regulation F 0689, which governs facilities' responsibilities for resident safety and supervision. The "few residents" affected by the tracking failures represent a breakdown in one of nursing homes' most basic obligations — knowing where their residents are.
The director's explanation to inspectors revealed a facility struggling with staffing consistency. Heavy reliance on agency workers, combined with inadequate training on essential procedures, left residents' safety dependent on a voluntary sign-out system that wasn't being enforced.
The inspection doesn't indicate whether Rocky Mountain Care has since improved its resident tracking procedures or reduced its dependence on agency staff. The facility's inability to account for residents' departures represents a fundamental failure in the duty of care that families expect when they place loved ones in professional nursing facilities.
For residents and their families, the breakdown meant periods when the facility couldn't say with certainty where residents were or when they might return. The consequences of such gaps extend beyond administrative inconvenience to genuine safety risks that federal regulators found serious enough to cite as a violation of care standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rocky Mountain Care - Cottage On Vine from 2025-11-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Rocky Mountain Care - Cottage on Vine in Murray, UT was cited for violations during a health inspection on November 5, 2025.
Federal inspectors responding to a complaint found the nursing home failed to properly monitor residents' departures from the building.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.