Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Monument Healthcare Cottonwood Creek during CMS and state inspections, most recent first.
The facility failed to ensure a hazard-free environment and adequate supervision for two residents with severe cognitive impairment and a history of falls. Despite multiple incidents, care plans were not consistently updated with new interventions, leading to repeated falls and injuries.
The facility failed to provide a safe, clean, comfortable, and homelike environment, with observations of soiled ceiling tiles, dusty air vents, and a persistent urine-like odor in the west hall. Staff interviews revealed gaps in cleaning responsibilities and maintenance, with the Administrator acknowledging that vents had not been cleaned as required.
The facility failed to report allegations of abuse and neglect to the SSA for six residents and did not conduct thorough investigations. Incidents involving resident altercations and falls resulting in injuries were not properly documented or reported, indicating a lack of compliance with regulatory requirements.
A resident with severe cognitive impairment and dependent on staff for personal hygiene was observed with long, soiled fingernails. Despite staff being trained to address refusals of care, there was a lack of consistent follow-up and communication, leading to poor grooming standards.
The facility failed to limit a PRN order for Ativan to 14 days, as required by regulations. A resident with severe cognitive impairment and multiple diagnoses was prescribed Lorazepam for over 21 days without an end date or documented rationale from the physician. The DON and CRN acknowledged the oversight during an interview.
The facility failed to protect residents from abuse, as evidenced by an incident where a male resident with a history of inappropriate sexual behaviors was found touching a female resident's breast. Both residents had significant cognitive impairments, and the male resident was not adequately monitored despite being on close observation. The female resident's care plan for wandering behavior was also insufficient to prevent the incident.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility did not ensure that the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Resident 56, who had severe cognitive impairment and a history of falls, was observed with a bandage on her head but was unable to explain the reason. Multiple incident reports documented falls, including one where the resident was found with a laceration requiring 20 sutures and 2 staples. Despite these incidents, the care plan was not consistently updated with new interventions to prevent further falls, and the Director of Nursing (DON) acknowledged that the fall care plan should have been more comprehensive and updated promptly after each incident. Resident 35, who also had severe cognitive impairment and a history of falls, was observed in her room with a bolster mattress but no fall mat. The resident had multiple documented falls, including one resulting in a non-displaced fibula fracture. Despite these incidents, the care plan was not consistently updated with new interventions to prevent further falls. The DON stated that the facility conducts a fall committee meeting weekly to discuss recent falls, trends, and new interventions, but the care plan updates were not always timely or comprehensive. Interviews with staff, including a CNA and an LPN, revealed that the protocol for unwitnessed falls included ensuring the resident's safety, initiating neurological checks, assessing for injuries, and completing incident reports. However, the documentation and implementation of new interventions in the care plans were inconsistent. The DON confirmed that new interventions should be placed in the care plan after each fall, but this was not always done, leading to repeated incidents without adequate preventive measures in place.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility did not provide a safe, clean, comfortable, and homelike environment as evidenced by multiple observations of soiled ceiling tiles, dusty air vents, and a persistent urine-like odor in the west hall. On several occasions, a strong smell of urine was noted throughout the west hall, which could not be traced to a specific room or resident. Certified Nursing Assistant (CNA) 3 confirmed the presence of the odor. Additionally, the facility environment was found to be in disrepair, with black, dusty substances on ceiling tiles and vents, cobwebs, dirty fingerprints, scuff marks, and an orange sticky substance on the walls. Writing in permanent marker was also observed on the wall between a room and the soiled linens closet. Interviews with staff revealed gaps in cleaning responsibilities and maintenance. The Housekeeper (HK) stated that she was responsible for cleaning specific areas but not the hallways and was unaware of any maintenance staff. The Administrator (ADMIN), who was temporarily filling in for maintenance staff, acknowledged that the vents should have been cleaned monthly but appeared to have been neglected for some time. The ADMIN also stated that the facility was typically free of offensive odors, contradicting the observations made during the survey.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility did not ensure that all allegations of abuse or neglect were reported to the State Survey Agency (SSA) for six of the 26 sampled residents. Additionally, the facility failed to report the results of all investigations of alleged abuse and neglect to the necessary officials, including the SSA, within the required five working days. This deficiency was identified through observation, interview, and record review, and it was determined that the facility had missed reporting several reportable allegations before achieving compliance on 3/15/2024. Resident 51 and Resident 23 were involved in an incident where Resident 51 slapped Resident 23, who then reciprocated. The incident was not reported to the SSA, and the facility did not complete the required investigation. Similarly, Resident 28 was found with injuries consistent with a fall, but the facility did not report the incident to the SSA or conduct a thorough investigation. Interviews with staff revealed inconsistencies in their accounts of the incidents and a lack of proper documentation. Resident 49 and Resident 35 were involved in another altercation where Resident 49 slapped Resident 35, who then pushed Resident 49, causing her to fall. This incident was also not reported to the SSA. Additionally, Resident 56 experienced two falls resulting in significant injuries, including a 10 cm head laceration requiring 20 sutures and 2 staples. These falls were not reported to the SSA, and the facility did not conduct the necessary investigations. Interviews with the DON and other staff members indicated a lack of understanding of the reporting requirements and the need for thorough investigations of such incidents.
Failure to Maintain Resident's Grooming and Hygiene
Penalty
Summary
The facility did not ensure that a resident with severely impaired cognitive skills received the necessary services to maintain good grooming. Specifically, Resident 28, who had diagnoses including dementia and was dependent on staff for personal hygiene, was observed with long fingernails and a brown substance under them. Despite being dependent on staff for self-care, the resident's nails were not properly maintained, leading to poor grooming standards. Interviews with staff revealed that while the resident sometimes refused care, staff were trained to try again later and involve a nurse if the resident continuously refused. However, there was a lack of consistent follow-up and communication among staff regarding the resident's hygiene needs. The Director of Nursing confirmed that staff should have reported the resident's refusal to a nurse and ensured that the nails were clipped as needed. The deficiency was observed over several days, indicating a failure in the facility's care processes for maintaining the resident's grooming and hygiene.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days, as required by regulations. Specifically, a PRN order for Ativan (Lorazepam) was prescribed for more than 21 days without an end date or documented rationale from the attending physician. The resident involved, identified as Resident 16, had multiple diagnoses including major depressive disorder, Alzheimer's disease, and anxiety disorder. The resident's medical record indicated severe cognitive impairment, and the PRN order for Lorazepam was initiated on 3/14/24 and administered on several occasions without adherence to the 14-day limitation rule. During an interview, the Director of Nursing (DON) and the Corporate Resource Nurse (CRN) acknowledged the oversight. The DON mentioned that the hospice company did not want to follow the 14-day rule, while the CRN admitted that the medication should have been limited to 14 days and possibly discontinued due to infrequent use. This failure to comply with the regulatory requirement for PRN psychotropic medications led to the identified deficiency.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility did not ensure that each resident was free from abuse, as evidenced by an incident involving two residents with significant cognitive impairment. A female resident was found in a male resident's room, where the male resident, seated in a wheelchair, had his hand up the female resident's shirt, touching her breast. Both residents were cognitively impaired, and the incident was identified as abuse by the facility. The male resident had a history of inappropriate sexual behaviors, including touching other residents and staff members, which had been documented in his medical records. Despite these behaviors, the male resident was not adequately monitored, leading to the incident with the female resident. The male resident had been exhibiting increased behaviors, including verbal aggression and inappropriate touching, which were being tracked by the nursing staff. He had been placed on close observation due to these behaviors, but the close observation was not consistently implemented or documented. On the day of the incident, staff were attending to another resident experiencing a medical emergency, which diverted their attention from monitoring the male resident. This lapse in supervision allowed the male resident to engage in inappropriate behavior with the female resident. The female resident had a history of wandering and impaired safety awareness due to Alzheimer's disease and other cognitive impairments. Her care plan included interventions to manage her wandering behavior, but these interventions were not sufficient to prevent her from entering the male resident's room. The facility's failure to adequately supervise both residents and implement effective interventions to manage their behaviors resulted in the incident of abuse.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 151 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Salt Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Ridge Rehabilitation And Nursing | 0 mi | ★★★★★ | 0 | 0 |
| City Creek Post Acute | 0.5 mi | ★★★★★ | 6 | 0 |
| William E Christofferson Salt Lake Veterans Home | 2.1 mi | ★★★★★ | 7 | 0 |
| Pine Creek Rehabilitation And Nursing | 2.1 mi | ★★★★★ | 8 | 0 |
| St Joseph Villa | 2.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.