Cycle 1
Health 2025-06-17 · Fire 2025-06-17
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tooele, UT
Rocky Mountain Care - Willow Springs
4-star overall rating with 3-star inspections with $40,733 in total fines with 6 recent health deficiencies
85 East 2000 North, Tooele, UT
(435) 843-2000
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
101
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Rocky Mountain Care
Operator or chain grouping
Approved since
1982-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.75
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
3.64
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,513
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.05
Composite VBP score used to determine payment impact.
Payment multiplier
1.0111
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.10
Baseline 19.73% · Performance 17.68% · Measure score 8.10 · Achievement 8.10 · Improvement 7.09
Healthcare-associated infections
9.29
Baseline 4.78% · Performance 5.06% · Measure score 9.29 · Achievement 9.29 · Improvement 0
Total nurse turnover
3.68
Baseline 62.40% · Performance 48.62% · Measure score 3.68 · Achievement 3.68 · Improvement 3.17
Adjusted total nurse staffing
1.35
Baseline 3.48 hours · Performance 3.46 hours · Measure score 1.35 · Achievement 1.35 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.86% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 319 · Observed rate 8.46% · Lower 95% interval 7.83% |
| Discharge to community | 64.9% |
50.57%
14.3 pts better
|
Better than the National Rate · Eligible stays 291 · Observed rate 64.6% · Lower 95% interval 60.34% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.01% |
95.27%
2.7 pts better
|
Numerator 197 · Denominator 201 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 201 |
| Discharge self-care score | 43.11% |
53.69%
10.6 pts worse
|
Numerator 72 · Denominator 167 |
| Discharge mobility score | 56.89% |
50.94%
6 pts better
|
Numerator 95 · Denominator 167 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 199 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.06% |
7.12%
2.1 pts better
|
No Different than the National Rate · Eligible stays 177 · Observed rate 2.26% · Lower 95% interval 2.95% |
| Staff COVID-19 vaccination coverage | 36.08% |
8.2%
27.9 pts better
|
Numerator 57 · Denominator 158 |
| Staff flu vaccination coverage | 62.5% |
42%
20.5 pts better
|
Numerator 135 · Denominator 216 |
| Discharge function score | 47.9% |
56.45%
8.6 pts worse
|
Numerator 80 · Denominator 167 |
| Transfer of health information to provider | 93.55% |
95.95%
2.4 pts worse
|
Numerator 29 · Denominator 31 |
| Transfer of health information to patient | 96.99% |
96.28%
0.7 pts better
|
Numerator 129 · Denominator 133 |
| Resident COVID-19 vaccinations up to date | 18.27% |
25.2%
6.9 pts worse
|
Numerator 19 · Denominator 104 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.5 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.9 · Expected 2.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.8%
3.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.0%
2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
2.6%
1.9 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 4.3% · Q3 3.0% · Q4 4.2% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.4% |
16.1%
6.7 pts better
|
11.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 7.5% · Q3 6.2% · Q4 20.3% · 4Q avg 9.4% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
3.8%
1 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 0.0% · Q3 3.6% · Q4 0.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
24.1%
2.9 pts better
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.9% · Q2 20.3% · Q3 23.2% · Q4 19.4% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.8% |
15.4%
9.6 pts better
|
16.7%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.1% · Q3 4.3% · Q4 5.4% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.1%
0.2 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.3% |
18.3%
6 pts worse
|
16.3%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 17.6% · Q4 30.9% · 4Q avg 24.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
13.6%
1.2 pts better
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 14.1% · Q3 14.8% · Q4 9.8% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.9%
0.9 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.4% · Q3 1.5% · Q4 1.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.8%
0.7 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.4% · Q3 0.0% · Q4 1.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
22.4%
4.7 pts better
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 17.6% · Q3 16.3% · Q4 23.0% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.1%
0.7 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.7% · Q3 3.6% · Q4 3.3% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
93.3%
6.5 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.0% |
11.8%
2.2 pts worse
|
12.0%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 13.3% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
0.9%
About the same
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
91.0%
8.1 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.9% |
17.4%
3.5 pts better
|
23.9%
10 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 12.7% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-21 · Fire 2023-08-21
9 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-10-18 · Fire 2021-10-18
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-08-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-08-21
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-08-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-08-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-08-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-08-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-08-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-10
F · Potential for more than minimal harm
2021-10-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-11-15
F · Potential for more than minimal harm
2021-10-18
K908 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.
Corrected 2021-12-01
D · Potential for more than minimal harm
2021-10-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-12-01
D · Potential for more than minimal harm
2021-10-18
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2021-12-03
D · Potential for more than minimal harm
2021-10-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-12-01
Inspection history
Recent health citations
G · Actual harm
2025-06-17
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-17
D · Potential for more than minimal harm
2025-06-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-27
D · Potential for more than minimal harm
2025-06-17
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-06-17
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-07-21
D · Potential for more than minimal harm
2025-06-17
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2025-07-22
D · Potential for more than minimal harm
2025-06-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-06-30
G · Actual harm
2024-08-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-08-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-02
F · Potential for more than minimal harm
2023-08-21
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-10-10
F · Potential for more than minimal harm
2023-08-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-08-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-08-21
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-08-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-01
D · Potential for more than minimal harm
2023-08-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-03
G · Actual harm
2021-10-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-12-01
G · Actual harm
2021-10-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-12-01
G · Actual harm
2021-10-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-12-01
F · Potential for more than minimal harm
2021-10-18
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2021-12-01
E · Potential for more than minimal harm
2021-10-18
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-12-01
E · Potential for more than minimal harm
2021-10-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-12-01
E · Potential for more than minimal harm
2021-10-18
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-12-01
E · Potential for more than minimal harm
2021-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-01
E · Potential for more than minimal harm
2021-10-18
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2021-12-01
D · Potential for more than minimal harm
2021-10-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-12-01
D · Potential for more than minimal harm
2021-10-18
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-12-01
D · Potential for more than minimal harm
2021-10-18
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2021-12-01
D · Potential for more than minimal harm
2021-10-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-12-01
D · Potential for more than minimal harm
2021-10-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-12-01
Penalties and ownership
What sits behind the stars
$9,110
2025-06-17
Fine
Fine · fine $9,110
Fine
$31,623
2024-08-01
Fine
Fine · fine $31,623
Fine
Ownership
Beaver City Corporation
5% Or Greater Indirect Ownership Interest · Organization
Bangerter, Edward
Operational/Managerial Control · Individual
Beeman, Raymond
Operational/Managerial Control · Individual
Boardman, Laura
Operational/Managerial Control · Individual
Hale, Fredrick
Operational/Managerial Control · Individual
Langford, Scott
Corporate Officer · Individual
Langford, Scott
W-2 Managing Employee · Individual
Mikesell, Bradley
Operational/Managerial Control · Individual
Moss, Tyler
Corporate Officer · Individual
Moss, Tyler
W-2 Managing Employee · Individual
Rehfeldt, Kristy
Operational/Managerial Control · Individual
Rocky Mountain Care - Tooele, Inc
Operational/Managerial Control · Organization
Rocky Mountain Care LLC
Operational/Managerial Control · Organization
Samuelson, Lance
Operational/Managerial Control · Individual
Widdison, Alan
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Copper Ridge Health Care
West Jordan, UT
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Meadow Peak Rehabilitation
Taylorsville, UT
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Rocky Mountain Care - Riverton
Riverton, UT
4-star overall rating with 3-star inspections with $33,212 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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