Above average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Little Cottonwood Rehabilitation And Nursing during CMS and state inspections, most recent first.
Resident records were not kept accurately or systematically organized when a shower preference form in one resident’s chart had another resident’s name, a consent form was filed in the wrong chart, and a lab result for one resident was found in another resident’s record. An LPN and the DON acknowledged the documentation errors, and the DON was observed removing the misplaced lab result from the hard chart.
A resident with severe cognitive impairment, ongoing psychosis, and a court order for mental health treatment was found engaged in a sexual act with another resident. Staff and documentation indicated the resident was delusional, unable to care for herself, and had no prior history of sexual conduct. The facility's assessment of her capacity to consent to sexual activity lacked evidence that she understood the risks or consequences, and the evaluation was not thoroughly documented or witnessed, resulting in a failure to ensure the resident was free from abuse.
Delayed Reporting of Alleged Sexual Abuse: A nurse found two residents in a sexual encounter, including one resident kissing the other and touching her breast over clothing. The event was not reported to the SSA until about 12 hours later, and the ADM stated it was not treated as sexual abuse because he believed it was consensual and there was no harm or serious bodily injury.
Nurse aide competency and training requirements were not met when an employee who started as a housekeeper was trained as a hospitality aide and later worked full-time as a nursing assistant without completing the full CNA training and competency process. The DON stated the aide had finished clinical training but still needed classroom hours before taking the exam.
MDS Assessments Incorrectly Coded Insulin Use: Three residents were coded on MDS assessments as receiving insulin during the seven-day lookback period even though the MARs and order histories showed no insulin administration or active insulin orders. Two residents had type 2 DM and were receiving weekly Ozempic, which the DON incorrectly treated as insulin, and a third resident had no insulin orders or documentation of insulin use.
Resident Records Contained Misfiled Forms and Lab Results
Penalty
Summary
Safeguard resident-identifiable information and maintain complete, accurately documented, readily accessible, and systematically organized medical records was not met for 5 of 19 sampled residents. The survey found that resident 13’s Shower Preference form in the chart had resident 38’s name printed at the top, although resident 13 had signed the form. An LPN stated the printed name should have been correct before the resident signed it and that the form should have been corrected before being placed in the chart. The survey also found that resident 38’s medical record contained a Consents/Authorizations form dated 5/21/25 with resident 15’s name on it, even though the DON stated the signature on the form was resident 38’s and that the document had been filed in the wrong chart. In addition, resident 5’s medical record contained a TSH laboratory result dated 6/3/25 for resident 27. An LPN stated that resident 27’s lab result should not have been in resident 5’s record, and the DON acknowledged the error and was observed removing the lab result from the hard chart.
Failure to Protect Resident with Severe Cognitive Impairment from Sexual Abuse
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of schizoaffective disorder, delusions, and hallucinations was found engaged in a sexual act with another resident. The incident was discovered by a registered nurse during a night shift, who observed the male resident kissing and touching the female resident in a bathroom. The female resident was described as smiling and not in distress at the time, and she verbally indicated she was fine with the interaction. However, her medical records consistently documented severe cognitive impairment, a BIMS score of 00, and ongoing psychosis, delusions, and disorganized thought processes. She was under a court order for mental health treatment and required daily management of her psychiatric needs. The facility's internal investigation concluded that the incident was consensual based on the resident's affect and statements. The assessment of the resident's capacity to consent to sexual activity was documented as positive, but the evaluation lacked evidence that the resident understood the relevant information, risks, or consequences of sexual activity. There was no documentation showing that the resident could verbalize or comprehend these risks, and the assessment form did not specify what information was discussed or understood. Interviews with staff, including CNAs and LPNs, indicated that the resident was known for delusional and childlike behaviors, with no prior history of sexual conduct with other residents. Staff also reported that such behavior would be unusual for her and that they would expect to be notified if it occurred. The Director of Nursing and other staff described the resident as having moments of clarity but generally being confused, delusional, and unable to care for herself. The DON stated that the resident was able to express her needs and make decisions, but the documentation and interviews did not demonstrate that the resident had the cognitive ability to consent to sexual activity. The evaluation for capacity to consent was conducted by the DON alone, with no other witnesses present, and the form was signed by another staff member who was not present. The lack of thorough documentation and assessment of the resident's understanding of the situation led to the facility's failure to ensure the resident was free from abuse.
Delayed Reporting of Alleged Sexual Abuse
Penalty
Summary
The facility did not ensure that an allegation involving abuse was reported immediately, and no later than 2 hours after the allegation was made, to the administrator and the State Survey Agency when the event involved abuse or resulted in serious bodily injury. The deficiency involved 1 of 20 sampled residents, with resident identifiers 30 and 41 referenced in the investigation. Resident 30 had diagnoses including schizoaffective disorder, bipolar type, cocaine dependence, and drug induced subacute dyskinesia. According to the facility abuse investigation, around 2:00 AM on 08/23/24, RN 1 noticed Resident 41's walker outside the main bathroom and found Resident 41 kissing Resident 30, with his right hand on her left breast over her clothing. The Form 358 documented that the State Survey Agency was notified at 2:13 PM on 08/23/24, approximately 12 hours after the incident occurred. During interviews, the Administrator stated he and the Resident Advocate worked together on abuse investigations and that he usually submitted the form to the SSA, but he did not identify the event as sexual abuse because he believed it was consensual sexual behavior. On follow-up, the Administrator stated the incident was not reported immediately because there was no harm or serious bodily injury.
Nurse Aide Worked Full-Time Without Completing Required Training
Penalty
Summary
The facility did not ensure that a nurse aide who had worked more than 4 months on a full-time basis was competent to provide nursing and nursing-related services and had completed a training and competency evaluation program approved by the State. Surveyors reviewed employee records and found that NA 1 had a start date of 10/17/23 as a housekeeper. During an interview, the DON stated that NA 1 was initially trained as a hospitality aide and continued training to become a CNA, completed clinical nursing assistant training in May 2024, but still needed classroom hours before taking the exam. The DON also stated that NA 1 had been scheduled and worked as a full-time nursing assistant since January 2025.
MDS Assessments Incorrectly Coded Insulin Use
Penalty
Summary
The facility did not ensure that resident assessments accurately reflected residents’ status. For 3 of 20 sampled residents, the MDS assessments coded the residents as having received insulin during the seven-day lookback period even though the medical record did not show any insulin administration. Resident 2 had diagnoses including secondary parkinsonism, disorder of brain, schizoaffective disorder, depressive type, personality disorder, and type 2 diabetes mellitus. Resident 7 had diagnoses including disorder of brain, schizoaffective disorder, bipolar type, and type 2 diabetes mellitus. For both residents, the quarterly MDS assessments documented insulin use on one of seven days, but the order history showed no insulin orders after 10/1/24 and the MAR contained no documentation of insulin administration after that date. Resident 28 had diagnoses including disorders of brain, schizoaffective disorder bipolar type, and idiopathic gout. The resident’s quarterly and annual MDS assessments also documented insulin use on one of seven days of the lookback period, but the order history for the last year showed no insulin orders or previous orders for insulin and the MAR showed no documentation that insulin had been given. During interview, the DON stated she completed and submitted the MDS reports and said none of the residents in the facility were ordered insulin. The DON stated that residents 2 and 7 were ordered weekly Ozempic injections and considered Ozempic to be insulin because it was injected and controlled blood sugar. The record also noted that Ozempic is non-insulin and works with the body’s own ability to lower blood sugar.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near South Salt Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadow Brook Rehabilitation And Nursing | 0.8 mi | ★★★★★ | 14 | 0 |
| Monument Healthcare South Salt Lake | 1.1 mi | ★★★★★ | 0 | 0 |
| Paramount Health And Rehabilitation | 1.4 mi | ★★★★★ | 1 | 0 |
| Monument Healthcare Murray Creek | 1.5 mi | ★★★★★ | 2 | 0 |
| St Joseph Villa | 1.8 mi | ★★★★★ | 0 | 0 |
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