Intermountain Health Holy Rosary Hospital

In the surveyor’s words

From the most serious findings on record at Intermountain Health Holy Rosary Hospital, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 27, 2026

  Based on interview and record review, the facility neglected to ensure resident-specific care plan interventions were implemented requiring use of a gait belt and continuous physical support during transfers. for 1 (#1) of 3 residents sampled for falls. The failure resulted in the resident sustaining an uncontrolled fall with increased pain requiring emergency department evaluation and subsequent transition to palliative care for pain management. Findings include:Review of a Facility-Reported Incident, submitted to the State Survey Agency on 5/11/26, showed resident #1 experienced a witnessed fall on 5/3/26 while staff assisted the resident from her room to a recliner in the sitting area. […]

• Actual harm, isolatedF686Feb 16, 2023

  Based on interview and record review, the facility failed to prevent the development of two Unstageable pressure areas; failed to obtain physician orders and an OT evaluation timely for the pressure areas; and failed to document the treatment and monitoring for healing of the pressure areas, for 1 (#19) of 3 sampled residents. Findings include: Review of the facility matrix, showed resident #19 had an Unstageable facility acquired pressure area. Review of resident #19's nursing entry note, dated 11/25/22, showed resident #19 was crying, and clearly stated her hands hurt. Review of resident #19's Annual MDS, with the ARD of 1/16/23, showed she had severe cognitive impairment. […]

• No harm, potential for more than minimal, widespreadF868Apr 23, 2026

  Based on interview and record review, the facility failed to ensure the medical director or his designee attended and/or participated in the Quality Assurance (QA) program at least quarterly. This deficient practice increased the risk of negative outcomes for residents with respect to quality assessment and assurance activities. The facility reported a census of 54 residents. Findings include:During an interview on 4/20/26 at 3:13 p.m., staff member A stated staff member G was onsite at the facility once a month. She stated when staff member G was onsite at the facility, it did not always correspond with when QA was scheduled to meet. […]

• No harm, potential for more than minimal, widespreadF941Apr 23, 2026

  Based on interview and record review, the facility failed to provide required effective communication training to all direct care staff. This deficient practice had the potential to affect the care of all residents residing in the facility. Findings include:During an interview on 4/22/26 at 1:30 p.m., staff member A stated the last all staff training which would have included effective communication was last provided on 8/29/24. She stated the next all staff training on effective communication was due 8/29/25. Staff member A stated they did establish a training program, which included effective communication, which they failed to implement by 8/29/25. […]

• No harm, potential for more than minimal, widespreadF943Apr 23, 2026

  Based on interview and record review, the facility failed to provide required dementia training to include management of dementia related behaviors to all staff. This deficient practice had the potential to affect the care of residents with dementia health needs in the facility. Findings include:During an interview on 4/22/26 at 1:30 p.m., staff member A stated the last all staff dementia training occurred on 8/29/24. She stated the next annual dementia training was due 8/29/25. Staff member A stated all staff have not been provided dementia training since 8/29/25. She stated they did establish a training program for dementia which they failed to implement by 8/29/25. […]