Rocky Mountain Care - Willow Springs
85 East 2000 North, Tooele, UT 84074 · Tooele County · 112 certified beds · avg 108 residents/day · certified since Jan 1, 1982
Part of chain: ROCKY MOUNTAIN CARE (10 facilities, chain avg rating 3.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
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)
▲ Actual harm, one-off · Jun 17, 2025 · F-0689 · triggered by a complaint
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: Jun 17, 2025 (Past Non-Compliance)
▲ Actual harm, one-off · Aug 1, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
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: Aug 30, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 18, 2021 · 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: Dec 1, 2021 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 18, 2021 · F-0697
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
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: Dec 1, 2021 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 18, 2021 · F-0757
The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Why it matters: Unneeded drugs expose residents to side effects, drowsiness, falls, and dangerous interactions.
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: Dec 1, 2021 (Deficient, Provider has date of correction)
All citations in the current public record (32)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 31, 2026 | D · Potential for harm, one-off | 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. · from a complaint |
| Mar 31, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 31, 2026 | D · Potential for harm, one-off | The 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 17, 2025 | ▲ G · Actual harm, one-off | The 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 17, 2025 | D · Potential for harm, one-off | The 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. |
| Jun 17, 2025 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Jun 17, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jun 17, 2025 | D · Potential for harm, one-off | The facility did not keep complete, dated laboratory records in residents' files. |
| Jun 17, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Aug 1, 2024 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Aug 1, 2024 | D · Potential for harm, one-off | 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. · from a complaint |
| Aug 1, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 21, 2023 | F · Potential for harm, facility-wide | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| Aug 21, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 21, 2023 | E · Potential for harm, repeated | 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. |
| Aug 21, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Aug 21, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Aug 21, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Oct 18, 2021 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Oct 18, 2021 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Oct 18, 2021 | ▲ G · Actual harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Oct 18, 2021 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Oct 18, 2021 | E · Potential for harm, repeated | The 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. |
| Oct 18, 2021 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Oct 18, 2021 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Oct 18, 2021 | E · Potential for harm, repeated | 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. |
| Oct 18, 2021 | E · Potential for harm, repeated | The facility did not report COVID-19 data to residents and their families as required. Facilities must keep residents and families informed about COVID-19 cases. |
| Oct 18, 2021 | D · Potential for harm, one-off | The 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. |
| Oct 18, 2021 | D · Potential for harm, one-off | The 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. |
| Oct 18, 2021 | D · Potential for harm, one-off | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Oct 18, 2021 | D · Potential for harm, one-off | The 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. |
| Oct 18, 2021 | D · Potential for harm, one-off | 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. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (6 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 14 | 3 | G ▲ |
| 2023 | 6 | 0 | F |
| 2024 | 3 | 1 | G ▲ |
| 2025 | 6 | 1 | G ▲ |
| 2026 | 3 | 0 | D |
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 $40,892.
| Date | Type | Amount / length |
|---|---|---|
| Jun 17, 2025 | Fine | $9,269 |
| Aug 1, 2024 | Fine | $31,623 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Utah avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.63 | 3.87 | 3.95 | top 47% in Utah; bottom 43% in the U.S. |
| Registered Nurse hours | 0.65 | 1.17 | 0.69 | bottom 10% in Utah; top 41% in the U.S. |
| Weekend total nurse staffing | 3.20 | 3.39 | 3.50 | top 40% in Utah; bottom 42% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.38 | 0.88 | 0.48 | bottom 4% in Utah; bottom 48% in the U.S. |
| Total nursing staff turnover (%) | 54.3 | 50.7 | 45.8 | bottom 38% in Utah; bottom 26% in the U.S. |
| RN turnover (%) | 52.4 | 40.6 | 42.9 | bottom 33% in Utah; bottom 32% 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 3.63, RN 0.65, weekend 3.20. Staffing rating: 3/5.
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: 5/5 · short-stay residents: 5/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Beaver City Corporation | Organization | 5% or Greater Direct Ownership Interest | 100% | 08/01/2015 |
| Bangerte, Nathan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2025 |
| Bangerter, Edward | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2025 |
| Bangerter, Johnathan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2025 |
| Barney, Janett | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2012 |
| Beeman, Raymond | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/22/2022 |
| Biddulph, Glen | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2025 |
| Biddulph, Glen | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2025 |
| Boardman, Laura | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/22/2022 |
| Brown, Gary | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2011 |
| Darby, Megan | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2025 |
| Gatherum, Jason | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2025 |
| Hale, Fredrick | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/22/2022 |
| Hansen, Kent | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2025 |
| Langford, Scott | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2018 |
| Mikesell, Bradley | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/22/2022 |
| Moss, Tyler | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2018 |
| Neves, Courtney | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2025 |
| Oakden, Richard | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2010 |
| Ottley, Brett | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/13/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Copper Ridge Health Care | 16.9 mi | West Jordan, UT | ★★★☆☆ | 2/5 | |
| Meadow Peak Rehabilitation | 17.2 mi | Taylorsville, UT | ★★★☆☆ | 3/5 | |
| Rocky Mountain Care - Riverton | 17.6 mi | Riverton, UT | ★★★★☆ | 3/5 | |
| Legacy Village Rehabilitation | 18.3 mi | Taylorsville, UT | ★★☆☆☆ | 3/5 | |
| Rocky Mountain Care - Hunter Hollow | 18.7 mi | West Valley City, UT | ★★☆☆☆ | 1/5 | |
| Stonehenge of South Jordan | 19.4 mi | South Jordan, UT | ★★★★★ | 5/5 | |
| Neurorestorative | 19.4 mi | Riverton, UT | ★★★★☆ | 3/5 | |
| Monument Healthcare Taylorsville | 19.5 mi | Salt Lake City, UT | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 465089.