Rocky Mountain Care - Hunter Hollow
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
listed the following corrective actions taken: The facility has completed a building audit on all residents that are on an air mattress on 11/17/2025 and an in-service has been done with CNA's to educate them on all residents that are on an air mattress need to be 2 person assist for bed mobility. Observe 5 staff during care (bed mobility, transfer, repositioning) weekly X4 weeks; then 5 staff monthly X2 months. Any resident that is on an air mattress will have a care plan for a 2 person assist for bed mobility. On 10/10/25, resident 5's provider ordered an air mattress. A care plan intervention dated 5/2/25 initiated the intervention: Hoyer lift for transferring with two person total assist. A care plan intervention dated 11/15/25 initiated the intervention: [Resident 5] has Air Mattress, needs two person assisted cares. On 12/22/25 at 2:57 PM, an
interview was conducted with Nursing Assistant (NA) 1. NA 1 stated that she was notified of residents requiring a two person assist when she received report at shift change. NA 1 was unaware of any changes
in care for residents with an air mattress, noting that the only resident she cared for who had an air mattress required a one person assist. On 12/22/25 at 3:06 PM, an interview was conducted with CNA 2.
CNA 2 stated that she knew resident requirements for a two person assist from the shift change report or based on her observations of the resident. CNA 2 stated if a resident was unable to hold themselves up
during care that she would request help from another CNA. CNA 2 stated that a resident on an air mattress could require a one- or two-person assist, depending on their individual ability to help with positioning. CNA 2 stated that she cared for a resident who used an air mattress and required a one person assist because
he could roll over and support himself. On 12/22/25 at 2:00 PM, an interview was conducted with the DON.
The DON stated that because resident 5 was on an air mattress she should have been a two person assist at the time of the incident. The DON stated that following the incident, the facility updated the care plans for all residents using an air mattress to require a two person assist. The DON stated that they provided education at an all staff meeting and nursing management went to individual staff to educate them. The DON stated that staff could use the Kardex tool in the electronic medical records to determine if a resident is a one person or a two person assist. The DON stated that after CNAs were provided the education management had been making observations of cares and transfers to make sure they were doing the two person assist when care planned.
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Rocky Mountain Care - Hunter Hollow in West Valley City, UT inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in West Valley City, UT, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Rocky Mountain Care - Hunter Hollow or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.