Rocky Mountain Care - Hunter Hollow
Rocky Mountain Care - Hunter Hollow in West Valley City, UT — inspection on December 22, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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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