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Nursing HomeMedicaid Investigative

Rocky Mountain Care - Cottage on Vine

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

835 East Vine Street, Murray, UT 8410761 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.2/5

based on 142 Google reviews

5
4
3
2
1
Rocky Mountain Care - Cottage on Vine Nursing Home in Murray, UT — Street View
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6/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (17 vs median 7)
  • High staff turnover (78%)
  • High RN turnover (77%)

Bottom 25% in UT · Meets national RN staffing standard · Very high staff turnover · Below chain average · $110,770 in fines

Source: Medicare data

What this means for your family

The facility has seen a significant influx of positive reviews since 2024, suggesting that recent management changes have improved the culture and care quality. However, given the history of serious safety and medication concerns, we strongly advise families to conduct an unannounced visit and specifically ask for the current medication administration protocols and staff-to-resident ratios.

Google Reviews

Google Reviews

142 reviews on Google
Rocky Mountain Care - Cottage on Vine receives polarized feedback, with many recent reviews praising a significant improvement in management, staffing, and resident engagement. However, long-term and past reviews highlight serious concerns regarding neglect, medication errors, and high staff turnover that families should investigate thoroughly. While the facility is often described as 'home-like' and 'charming' by current supporters, the history of critical safety complaints warrants caution.

Quality Themes

Tap a score for details
Food7.0Staff6.0Clean6.0Activities9.0Meds3.0MemoryN/AComms5.0ValueN/A

Strengths

  • Warm, attentive nursing and CNA staff
  • Engaging activities and recreation program
  • Strong physical therapy department
  • Recent improvements in management and leadership

Concerns

  • Medication management errors and administration issues (mentioned by 4 reviewers)
  • Understaffing leading to neglect and slow response times (mentioned by 7 reviewers)
  • Small, cramped rooms with shared bathrooms (mentioned by 4 reviewers)
  • High staff turnover and reliance on agency personnel (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'15(1)'18(3)'20(3)'22(6)'24(16)'26(24)

Distribution · 126 analyzed

5
99
4
3
3
1
2
1
1
22
21 reviews posted between Jul 28, 2025Jul 31, 2025 · 21 were 5-star
10 reviews posted between Jun 8, 2025Jun 14, 2025 · 10 were 5-star

How They Respond to Reviews

90%response rate

This facility actively engages with reviewer feedback.

Questions for Your Tour

  • 1I noticed the facility has been working on management improvements lately; what specific changes have been implemented to help with staff consistency and reduce reliance on agency personnel?
  • 2With the current staffing levels, what is your facility's protocol for ensuring timely responses to call lights and resident requests?
  • 3Given that medication administration is a complex process, could you walk me through the safety checks and oversight measures you have in place to prevent errors?
  • 4The activity program seems to be a real highlight here; what are some of the most popular social or recreational events that residents look forward to each week?
  • 5I see that some of the rooms feature shared bathrooms; how do you manage privacy and cleanliness in those shared spaces to ensure resident comfort?
  • 6I appreciate that the leadership team is active in responding to feedback online; how do you incorporate that kind of family input into your day-to-day operations?

Personalized based on this facility's data


Key Review Excerpts

The first thing I noticed when my wife was admitted to Rocky Mountain Care-Cottage on Vine after her stroke was the cleanliness of the facility and patient rooms. Next as we became familiar with the staff and GREAT nurses, we experienced a genuine love and dedication to my wife.

Long-term resident's family · 2017★★★★★

The building is grim - tiny rooms with two people per room and beds placed so it felt like he was in a closet. Worn out furniture and, in my father's case a light with a broken cord he couldn't reach.

Rehab patient's family · 2021★★☆☆☆

Under Madi M and Gerald N the facility has made many improvements to resident care and staffing. They understand the needs of everyone who comes in the building (residents, families, staff) and do their best to help wherever they're needed.

Staff/Observer · 2025★★★★★
Source: 142 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
1.06hrs
OK
Registered nurses for medical care
Total Nursing
3.26hrs
79%
All nurses + aides combined
Staff Turnover
71%
Lower is better (< 30% = good)
RN Turnover
86%
Lower is better (< 30% = good)

Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

9

measures

Worse Than Avg

5

measures

Mixed Results

3

measures

Long-Stay Residents
🚶

Residents whose walking got worse

↓ Lower is better
This Facility34.0%
Worse than Avg
Here
34.0%
US
15.3%
UT
16.8%
Salt lake
14.2%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility13.1%
Better than Avg
Here
13.1%
US
19.5%
UT
24.7%
Salt lake
22.3%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility4.1%
Better than Avg
Here
4.1%
US
15.5%
UT
14.6%
Salt lake
14.2%
😔

Residents with depression symptoms

↓ Lower is better
This Facility12.9%
Mixed vs Avgs
Here
12.9%
US
12.1%
UT
16.5%
Salt lake
23.3%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility19.8%
Worse than Avg
Here
19.8%
US
14.4%
UT
12.1%
Salt lake
10.5%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility26.2%
Worse than Avg
Here
26.2%
US
19.4%
UT
21.8%
Salt lake
21.2%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility98.8%
Better than Avg
Here
98.8%
US
81.8%
UT
93.8%
Salt lake
94.3%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility91.8%
Better than Avg
Here
91.8%
US
79.8%
UT
91.0%
Salt lake
91.7%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
UT
0.8%
Salt lake
0.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

17deficiencies
3penalties
Well above state avg (9.1)
19 complaint-triggered
$110,770 in fines

Families have filed reports triggering inspections, revealing recurring concerns about resident safety and abuse protection protocols that have persisted across multiple surveys spanning 2022-2025. The facility has shown repeated deficiencies in safety supervision (preventing accidents and falls), medication management, and abuse reporting procedures. While all violations have been formally corrected, the pattern of ongoing issues in these critical areas warrants careful consideration during your visit.

Nov 5, 2025Complaint
1
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Mar 6, 2025Routine
16
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0760Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0775Potential for harm · PatternCorrected

Administration Deficiencies

Keep complete, dated laboratory records in the resident's record.

0803Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0582Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0622Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

0881Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

May 15, 2024Complaint
5
0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0740Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Nov 8, 2023Routine
2
0880Actual harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Nov 8, 2023Complaint
8
0609Potential for harm · PatternCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0725Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0602Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Sep 21, 2023Complaint
4
0690Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0770Actual harm · IsolatedCorrected

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Federal Penalties

Fine

Nov 8, 2023

$55,999

Fine

Sep 21, 2023

$22,947

Payment Denial

Sep 21, 2023

4-day denial

Ownership & Operations

Who Operates This Facility

Owner / Operator

Rocky Mountain Care - Cottage on Vine

Organization Type

for profit

Chain Affiliation

Chain Name

Rocky Mountain Care

Chain Size

10 facilities nationwide

Chain avg rating: 3.0/5 · Rank 7 of 9

Ownership & Management

Owners

Beaver City Corporation

Owner · Organization

100%

Key personnel

Bangerte, NathanManaging Control - Governing BodyBangerter, EdwardManaging Control - Governing BodyBangerter, JohnathanManaging Control - Governing BodyBarney, JanettManaging Control - Governing BodyBeeman, RaymondManaging Control - Governing Body
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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