Monument Healthcare Cottonwood Creek

Name: Monument Healthcare Cottonwood Creek
Address: 1205 East Bonner Way, Salt Lake City, UT, 84117, US
Telephone: 8012622908

1205 East Bonner Way, Salt Lake City, UT 84117 · Salt Lake County · 77 certified beds · avg 65 residents/day · certified since May 16, 1980

Part of chain: MONUMENT HEALTH GROUP (11 facilities, chain avg rating 2.8★)

2/5

Health inspection rating (on-site)

Serious findings on record

$17,940

Fines, last 3 years

3.69

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5

⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Apr 4, 2024 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Apr 25, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · May 5, 2022 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jun 9, 2022 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · May 5, 2022 · F-0692

The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.

Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jun 9, 2022 (Deficient, Provider has date of correction)

All citations in the current public record (28)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Apr 4, 2024	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 4, 2024	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Apr 4, 2024	E · Potential for harm, repeated	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Apr 4, 2024	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Apr 4, 2024	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Apr 4, 2024	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
May 5, 2022	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 5, 2022	▲ G · Actual harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
May 5, 2022	E · Potential for harm, repeated	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
May 5, 2022	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 5, 2022	E · Potential for harm, repeated	The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.
May 5, 2022	E · Potential for harm, repeated	The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
May 5, 2022	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 5, 2022	E · Potential for harm, repeated	The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
May 5, 2022	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
May 5, 2022	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
May 5, 2022	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
May 5, 2022	D · Potential for harm, one-off	The facility did not provide timely, quality laboratory tests to meet residents' needs.
May 5, 2022	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Dec 5, 2019	E · Potential for harm, repeated	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Dec 5, 2019	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Dec 5, 2019	D · Potential for harm, one-off	The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Dec 5, 2019	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Dec 5, 2019	D · Potential for harm, one-off	The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Dec 5, 2019	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Dec 5, 2019	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Dec 5, 2019	D · Potential for harm, one-off	The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience.
Dec 5, 2019	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (13 → 6).

Year	Citations	Serious (G–L)	Worst severity that year
2019	9	0	E
2022	13	2	G ▲
2024	6	1	G ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $17,940.

Date	Type	Amount / length
Apr 4, 2024	Fine	$17,940

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Utah avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.69	3.87	3.95	top 40% in Utah; bottom 46% in the U.S.
Registered Nurse hours	0.95	1.17	0.69	bottom 43% in Utah; top 18% in the U.S.
Weekend total nurse staffing	3.29	3.39	3.50	top 36% in Utah; bottom 46% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.64	0.88	0.48	bottom 37% in Utah; top 20% in the U.S.
Total nursing staff turnover (%)	0.0	50.7	45.8	—
RN turnover (%)	0.0	40.6	42.9	—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.51, RN 0.90, weekend 3.13. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Clawson, Travis	Individual	Operational/Managerial Control	NOT APPLICABLE	02/07/2025
Clawson, Travis	Individual	ADP of the SNF	NOT APPLICABLE	02/07/2025
Espinosa, Stephanie	Individual	Operational/Managerial Control	NOT APPLICABLE	02/07/2025
Espinosa, Stephanie	Individual	ADP of the SNF	NOT APPLICABLE	02/07/2025
Fragoso, Lindsay	Individual	Operational/Managerial Control	NOT APPLICABLE	05/10/2021
Fragoso, Lindsay	Individual	ADP of the SNF	NOT APPLICABLE	05/10/2021
Gunnison Valley Hospital	Organization	Operational/Managerial Control	NOT APPLICABLE	02/07/2025
Gunnison Valley Hospital	Organization	ADP of the SNF	NOT APPLICABLE	03/24/2025
Health Group Management LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	02/07/2025
Health Group Management LLC	Organization	ADP of the SNF	NOT APPLICABLE	03/24/2025
Marriott, Stephen	Individual	Operational/Managerial Control	NOT APPLICABLE	02/07/2025
Marriott, Stephen	Individual	ADP of the SNF	NOT APPLICABLE	02/07/2025
McKinnie-Redmond, Faith	Individual	Operational/Managerial Control	NOT APPLICABLE	02/07/2025
McKinnie-Redmond, Faith	Individual	ADP of the SNF	NOT APPLICABLE	02/07/2025
Monument Health Group LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	02/07/2025
Monument Health Group LLC	Organization	ADP of the SNF	NOT APPLICABLE	03/24/2025
Monument Health Properties LLC	Organization	ADP of the SNF	NOT APPLICABLE	02/07/2025
Monument Real Estate Cottonwood Creek LLC	Organization	ADP of the SNF	NOT APPLICABLE	02/07/2025
Morris, Jace	Individual	Operational/Managerial Control	NOT APPLICABLE	02/07/2025
Morris, Jace	Individual	ADP of the SNF	NOT APPLICABLE	02/07/2025

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
"Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Monument Healthcare Millcreek	0.5 mi	Salt Lake City, UT	★★★★☆	3/5
Spring Creek Healthcare Center	1.1 mi	Salt Lake City, UT	★★☆☆☆	2/5
Highland Care Center	1.3 mi	Holladay, UT	★★★★★	4/5
Monument Healthcare Murray Creek	1.5 mi	Millcreek, UT	★★☆☆☆	1/5	abuse
Paramount Health and Rehabilitation	1.6 mi	Salt Lake City, UT	★★★☆☆	2/5
Rocky Mountain Care - Cottage on Vine	1.6 mi	Murray, UT	★★★☆☆	2/5
Holladay Healthcare Center	2.1 mi	Salt Lake City, UT	★★★☆☆	2/5
Aspen Ridge West Transitional Rehab	2.1 mi	Murray, UT	★★★★★	4/5
Aspen Ridge Transitional Rehab	2.5 mi	Murray, UT	★★★★★	5/5
Mt. Olympus Rehabilitation Center	2.7 mi	Salt Lake City, UT	★★☆☆☆	1/5
Little Cottonwood Rehabilitation and Nursing	3.0 mi	South Salt Lake, UT	★★★★★	5/5
Millcreek Rehabilitation and Nursing	3.0 mi	Salt Lake City, UT	★★☆☆☆	1/5	abuse

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 465074.

The Care File

Visit checklist — Monument Healthcare Cottonwood Creek

1205 East Bonner Way, Salt Lake City, UT 84117 · 8012622908

Health inspection rating 2/5 · CMS overall 3/5· Fines (3y): $17,940

Most serious findings on record:

▲ Apr 4, 2024 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ May 5, 2022 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ May 5, 2022 (F-0692, Actual harm, one-off): The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
☐ "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 465074 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)