Little Cottonwood Rehabilitation And Nursing
Little Cottonwood Rehabilitation and Nursing in South Salt Lake, UT — inspection on October 9, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
submitted it to the State Survey Agency (SSA). If he was not present then the RA would submit it on his behalf.
The ADM stated he did not indicate sexual abuse as an allegation when it was reported to the SSA because it was consensual sexual behavior.
The ADM stated that he would need to speak with the DON to determine why it was determined consensual. I was not present at the time.
The ADM stated that the DON let him know that the situation was consensual and the DON would have done an evaluation to make the determination that resident 30 had the capacity to consent to sexual activity. On 10/8/25 at 8:01 AM, an interview was conducted with the DON.
The DON stated that resident 30 had confusion but knows what she wants.
The DON stated that resident 30 was alert and oriented times 2-3 to person, place and sometimes situation.
The DON stated that resident 30 was more confused and delusional now, but had always been delusional.
The DON stated that resident 30's delusions were centered around famous people.
The DON stated that resident 30 believed she had nine children with [NAME].
The DON stated that a year ago resident 30 was more stable than she was currently.
The DON stated that resident 30 had said she was okay with the incident that occurred with resident 41.
The DON stated that she did not really know why resident 30 was court ordered for treatment but assumed it was because she did not want to be at the facility and wanted to go home.
The DON then stated that resident 30 was deemed not capable to care for herself and needed assistance with medication management.
The DON stated that resident 30's mother had stated that resident 30 was non-compliant with her medications.
The DON stated that resident 30 had moments of clarity with confusion, but was able to make her own decisions.
The DON stated that when she questioned resident 30 about the incident that occurred on 8/23/24 the resident gave the same explanation of the events, was content with it, and was happy with it.
The DON stated that resident 30 was fine with the other resident touching her.
The DON stated that resident 30 had episodes of mania, with some sexual behaviors such as believing she was having sex with famous people and having children with them.
The DON stated that resident 30 never made sexual comments about other residents.
The DON stated that when she evaluated resident 30 for the capacity to consent to sexual activity she asked resident 30 if she knew that she could get hurt if she invited other people to touch her.
The DON stated that resident 30 stated she understood.
The DON stated that at the time of the evaluation resident 30 was able to recall what she did prior to being admitted to the facility and that she had been admitted to a psychiatric inpatient unit.
The DON stated that resident 30 understood that she could not go home.
The DON stated that during the sexual capacity to consent evaluation she told resident 30 that her sexual activity and verbal comments were inappropriate and could invite other people to do stuff with her.
The DON stated that she asked resident 30 if she was okay with that and could she handle that, i.e. the sexual activity.
The DON stated that resident 30 replied that she was alright with that behavior. It should be noted that the evaluation did not specify what risks were associated with sexual activity and if resident 30 was able to understand those risks and the consequences of them.
Additionally, the evaluation did not demonstrate that resident 30 had the cognitive ability to consent to sexual activity, only that she appeared to want the contact.
The DON stated that the RA signed the evaluation form with her but was not present during the evaluation.
The DON stated that no one else was present with her during resident 30's evaluation for capacity to consent to sexual activity.
The DON stated that resident 30 had delusions with moments of clarity at the time of the evaluation.
The DON stated that resident 30's cognitive ability had declined since the incident.
Facility ID:
46A066
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.