Little Cottonwood Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Little Cottonwood Rehabilitation and Nursing, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Sep 28, 2022

  Based on interview, record review, and observation, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, cross contamination was observed in the kitchen during the dish cleaning process, the dishmachine did not reach the appropriate temperature, meals were not served appropriately, and multiple areas of the kitchen were observed to be soiled or in disrepair. Resident identifiers: 4 and 11. Findings include: 1. On 9/26/22 at 7:00 AM, Dietary Staff Member (DSM) 1 was observed in the kitchen next to the steam table area containing food. DSM 1 did not have a mask on. On 9/26/22 at 7:15 AM, an interview was conducted with DSM 1. DSM 1 stated that he did not like to wear masks because they were itchy. […]

• No harm, potential for more than minimal, patternF842Oct 9, 2025

  Based on interview and record review it was determined, for 5 out of 19 sampled residents, that the facility did not maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized. Specifically, a resident's assessment was labeled with another resident's name, a resident's laboratory results were located in another resident's medical records, and a resident's shower sheet had another resident's name listed on the form. Resident identifiers: 5, 13, 15, 27, and 38. Findings included:1. […]

• No harm, potential for more than minimal, patternF812Apr 13, 2021

  Based on observation and interview it was determined that the facility did not store and distribute food in accordance with professional standards for food service safety. Specifically, there were condiments in a metal baskets on the dining room tables that were not sanitized between meal service. In addition, there was peeling paint in the kitchen. Resident identifiers: 2, 10, 18 and 35. Findings include: 1. On 4/12/21 at 11:53 AM, an observation was made of the dining room. There was a meal schedule hanging in the dining room that revealed there were two meal services in the dining room. Tables were observed with one chair per table, with a caddy container of condiments located in the center of the table. […]

• No harm, potential for more than minimal, isolatedF600Oct 9, 2025

  Based on interview and record review it was determined, for 1 of 20 sampled residents, that the facility did not ensure that the resident was free from abuse. Specifically, a resident who lacked the capacity to consent to sexual activity was found engaged in a sexual act with another resident. Resident identifier: 30 and 41. Findings included: 1. Resident 30 was admitted to the facility on [DATE] with diagnoses which consisted of Schizoaffective disorder bipolar type, cocaine dependence, and drug induced subacute dyskinesia. On 10/6/25 at 9:47 AM, an interview was conducted with resident 30 while the resident was ambulating down the hallway. Resident 30 stated that she did not want to die, and someone was going to kill her. […]

• No harm, potential for more than minimal, isolatedF609Oct 9, 2025

  Based on interview and record review it was determined, for 1 out of 20 sampled residents, that the facility did not ensure that alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and the State Survey Agency (SSA). Specifically, an allegation of sexual abuse was not reported to the state survey agency for approximately 12 hours after the incident occurred. Resident identifiers: 30 and 41. Findings included:Resident 30 was admitted to the facility on [DATE] with diagnoses which consisted of Schizoaffective disorder bipolar type, cocaine dependence, and drug induced subacute dyskinesia. […]