Utah ›Murray

Rocky Mountain Care - Cottage on Vine

835 East Vine Street, Murray, UT 84107 · Salt Lake County · 61 certified beds · avg 44 residents/day · certified since May 30, 1991

Part of chain: ROCKY MOUNTAIN CARE (10 facilities, chain avg rating 3.0★)

2/5
Health inspection rating (on-site)
10
Serious findings on record
$78,946
Fines, last 3 years
3.30
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, repeated · Jun 13, 2022 · F-0600

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Jul 15, 2022 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, repeated · Jun 13, 2022 · F-0609

The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.

Why it matters: When incidents aren't reported promptly, abusers may continue harming residents and outside authorities can't step in.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Jul 15, 2022 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, repeated · Jun 13, 2022 · F-0610

The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.

Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: Jul 15, 2022 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, one-off · Jun 13, 2022 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jul 15, 2022 (Deficient, Provider has date of correction)

▲ Actual harm, repeated · Nov 8, 2023 · F-0880

The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.

Why it matters: Weak infection control lets illnesses like flu, COVID-19, and drug-resistant infections spread quickly among vulnerable residents.

Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.

Corrected: Dec 21, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Sep 21, 2023 · F-0690 · triggered by a complaint

The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.

Why it matters: Poor continence and catheter care leads to infections, skin breakdown, and loss of dignity.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 1, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Sep 21, 2023 · F-0770 · triggered by a complaint

The facility did not provide timely, quality laboratory tests to meet residents' needs.

Why it matters: Slow or unreliable lab work can delay diagnosis and treatment of serious conditions.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Nov 1, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jun 15, 2023 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jul 14, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jun 15, 2023 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jul 14, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jun 13, 2022 · F-0744

The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.

Why it matters: Poor dementia care can lead to distress, unsafe wandering, or unnecessary sedating medication.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jul 15, 2022 (Deficient, Provider has date of correction)

All citations in the current public record (57)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Nov 5, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Mar 6, 2025F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 6, 2025E · Potential for harm, repeatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Mar 6, 2025E · Potential for harm, repeatedThe facility did not keep complete, dated laboratory records in residents' files.
Mar 6, 2025E · Potential for harm, repeatedThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Mar 6, 2025D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Mar 6, 2025D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Mar 6, 2025D · Potential for harm, one-offThe facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Mar 6, 2025D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Mar 6, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Mar 6, 2025D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Mar 6, 2025D · Potential for harm, one-offThe facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Mar 6, 2025D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Mar 6, 2025D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Mar 6, 2025D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Mar 6, 2025D · Potential for harm, one-offThe facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective.
Mar 6, 2025D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
May 15, 2024D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
May 15, 2024D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
May 15, 2024D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
May 15, 2024D · Potential for harm, one-offThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint
May 15, 2024D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Nov 8, 2023▲ H · Actual harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 8, 2023E · Potential for harm, repeatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Nov 8, 2023E · Potential for harm, repeatedThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Nov 8, 2023E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Nov 8, 2023E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Nov 8, 2023D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
Nov 8, 2023D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Nov 8, 2023D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Nov 8, 2023D · Potential for harm, one-offThe facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Nov 8, 2023D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Sep 21, 2023▲ G · Actual harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Sep 21, 2023▲ G · Actual harm, one-offThe facility did not provide timely, quality laboratory tests to meet residents' needs. · from a complaint
Sep 21, 2023D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Sep 21, 2023D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jun 15, 2023▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jun 15, 2023▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jun 15, 2023D · Potential for harm, one-offThe facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Jun 15, 2023D · Potential for harm, one-offThe facility did not provide timely, quality laboratory tests to meet residents' needs.
Jun 15, 2023D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Jun 13, 2022▲ K · Immediate jeopardy, repeatedThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Jun 13, 2022▲ K · Immediate jeopardy, repeatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Jun 13, 2022▲ K · Immediate jeopardy, repeatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Jun 13, 2022▲ J · Immediate jeopardy, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jun 13, 2022▲ G · Actual harm, one-offThe facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.
Jun 13, 2022E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jun 13, 2022E · Potential for harm, repeatedThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Jun 13, 2022E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 13, 2022D · Potential for harm, one-offThe facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Jun 13, 2022D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Jun 13, 2022D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Jun 13, 2022D · Potential for harm, one-offThe facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them.
Jun 13, 2022D · Potential for harm, one-offThe facility did not keep signed and dated reports of x-rays and other diagnostic tests in residents' records.
Jun 13, 2022D · Potential for harm, one-offThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Jun 13, 2022D · Potential for harm, one-offThe facility did not perform required COVID-19 testing on residents and staff.
Jun 13, 2022D · Potential for harm, one-offThe facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (5 → 16).

YearCitationsSerious (G–L)Worst severity that year
2022165K ▲
2023195H ▲
202450D
2025170F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

2 fines totaling $78,946, plus 1 Medicare payment denial period.

DateTypeAmount / length
Nov 8, 2023Fine$55,999
Sep 21, 2023Fine$22,947
Sep 21, 2023Payment Denial4 days from Oct 28, 2023

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityUtah avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.303.873.95bottom 29% in Utah; bottom 26% in the U.S.
Registered Nurse hours0.961.170.69bottom 46% in Utah; top 17% in the U.S.
Weekend total nurse staffing2.903.393.50bottom 31% in Utah; bottom 26% in the U.S.
Weekend RN hours (not acuity-adjusted)0.600.880.48bottom 31% in Utah; top 23% in the U.S.
Total nursing staff turnover (%)70.450.745.8bottom 9% in Utah; bottom 5% in the U.S.
RN turnover (%)73.340.642.9bottom 7% in Utah; bottom 9% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.43, RN 1.00, weekend 3.02. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5

Who owns this facility

For profit - Individual

Owner / managerTypeRoleStakeSince
Beaver City CorporationOrganization5% or Greater Direct Ownership Interest100%04/12/2013
Bangerte, NathanIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2025
Bangerter, EdwardIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2025
Bangerter, JohnathanIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2025
Barney, JanettIndividualManaging Control - Governing BodyNOT APPLICABLE01/01/2012
Beeman, RaymondIndividualManaging Control - Governing BodyNOT APPLICABLE09/22/2022
Boardman, LauraIndividualManaging Control - Governing BodyNOT APPLICABLE09/22/2022
Brown, GaryIndividualManaging Control - Governing BodyNOT APPLICABLE01/01/2011
Darby, MeganIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2025
Gatherum, JasonIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2025
Hale, FredrickIndividualManaging Control - Governing BodyNOT APPLICABLE09/20/2022
Hansen, KentIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2025
Langford, ScottIndividualCorporate OfficerNOT APPLICABLE03/01/2018
Martinez, MarkIndividualOperational/Managerial ControlNOT APPLICABLE04/01/2023
Martinez, MarkIndividualADP of the SNFNOT APPLICABLE04/01/2023
Mikesell, BradleyIndividualManaging Control - Governing BodyNOT APPLICABLE09/22/2022
Moss, TylerIndividualCorporate OfficerNOT APPLICABLE03/01/2018
Neves, CourtneyIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2025
Oakden, RichardIndividualManaging Control - Governing BodyNOT APPLICABLE01/01/2010
Owens, JonIndividualManaging Control - Governing BodyNOT APPLICABLE11/01/2025

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Aspen Ridge Transitional Rehab1.0 miMurray, UT★★★★★5/5
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Aspen Ridge West Transitional Rehab1.9 miMurray, UT★★★★★4/5
Monument Healthcare Millcreek2.1 miSalt Lake City, UT★★★★☆3/5
Spring Creek Healthcare Center2.3 miSalt Lake City, UT★★☆☆☆2/5
Paramount Health and Rehabilitation2.7 miSalt Lake City, UT★★★☆☆2/5
Highland Care Center2.8 miHolladay, UT★★★★★4/5
Monument Healthcare Murray Creek3.0 miMillcreek, UT★★☆☆☆1/5abuse
Holladay Healthcare Center3.0 miSalt Lake City, UT★★★☆☆2/5
Cascades at Riverwalk3.0 miMidvale, UT★★★★☆3/5
Monument Healthcare Taylorsville3.7 miSalt Lake City, UT★★☆☆☆2/5
Sandy Health and Rehab4.1 miSandy, UT★☆☆☆☆1/5

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Facility data as of CMS processing date 2026-08-01. CCN 465125.