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Nursing HomeMedicaid

Monument Healthcare Cottonwood Creek

Meets baseline Medicare standards with room for improvement. A tour and talking to current residents' families is the best next step.

1205 East 4725 South, Salt Lake City, UT 8411777 bedsLicensed & Active
3/5
Medicare
Inspection
Quality
Staffing
Google rating
3.8/5

based on 29 Google reviews

5
4
3
2
1
Monument Healthcare Cottonwood Creek Nursing Home in Salt Lake City, UT — Street View
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What this means for your family

While many families appreciate the dedicated, long-term staff in the memory care unit, the reports of hygiene issues and medication mismanagement are significant red flags. We strongly advise conducting unannounced visits and speaking directly with current families in the memory care wing to verify the consistency of care before making a decision.

Google Reviews

Google Reviews

29 reviews on Google
Monument Healthcare Cottonwood Creek (formerly Willow Wood) receives highly polarized feedback, with some families praising the dedicated, compassionate staff while others report severe neglect and poor communication. While the facility is frequently described as older, many reviewers emphasize that the quality of care provided by the staff outweighs the building's aesthetic limitations. However, critical reports of medication mismanagement, hygiene issues, and inadequate supervision in the memory care unit are significant concerns for prospective families.

Quality Themes

Tap a score for details
Food7.0Staff6.0Clean5.0Activities6.0Meds2.0Memory4.0Comms4.0ValueN/A

Strengths

  • Compassionate, dedicated nursing staff
  • Strong, attentive memory care team
  • Homelike, quiet residential atmosphere
  • Responsive administrative leadership

Concerns

  • Neglect and poor hygiene in memory care (mentioned by 2 reviewers)
  • Medication management errors and delays (mentioned by 2 reviewers)
  • Inadequate staffing levels (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'16(1)'18(8)'20(1)'22(7)'24(2)'26(2)

Distribution · 34 analyzed

5
19
4
3
3
3
2
3
1
6

How They Respond to Reviews

55%response rate

This facility responds to some reviews.

Questions for Your Tour

  • 1I noticed that your administrative team is quite active in responding to feedback online; how does that focus on communication translate into how you keep families updated about their loved one's daily care?
  • 2Given that medication management is a critical part of resident health, what specific protocols or double-check systems do you have in place to ensure medications are administered accurately and on time?
  • 3I understand that maintaining a high standard of hygiene is essential, especially in memory care; what is your daily routine for ensuring residents' personal care needs are met consistently?
  • 4With a capacity of 77 residents, how does your current staffing model ensure that every resident receives timely attention, particularly during peak hours or shift changes?
  • 5Since your team is known for being compassionate and dedicated, how do you support your staff to ensure they have the time and resources to provide that personal touch to every resident?
  • 6What does a typical day look like for a resident in your memory care wing, and how do you tailor activities to keep them engaged and comfortable?

Personalized based on this facility's data


Key Review Excerpts

My dad is left wet and his mattress is socking wet to the point it has urine dripping. Some of the staff are amazing and some could care less

Memory care family member · 2023★★☆☆☆

The staff here is nothing short of amazing. My mom is currently spending her final days in the dementia unit and she requires a lot of extra attention. The staff does an incredible job going the extra mile for her.

Memory care family member · 2022★★★★★

I did not receive my pain medication as ordered by my doctor they kept telling me I had to wait 3 more hours every time I asked after waiting 3 hours I had to wait 3 more hours.

Rehab patient · 2020☆☆☆☆
Source: 29 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.85hrs
OK
Registered nurses for medical care
Total Nursing
3.38hrs
83%
All nurses + aides combined

Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
5/ 5
Better Than Avg

10

measures

Worse Than Avg

3

measures

Mixed Results

4

measures

Long-Stay Residents
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility32.4%
Worse than Avg
Here
32.4%
US
19.5%
UT
24.7%
Salt lake
21.6%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility6.7%
Better than Avg
Here
6.7%
US
15.3%
UT
16.8%
Salt lake
15.2%
⚠️

Residents who fell and were seriously hurt

↓ Lower is better
This Facility9.6%
Worse than Avg
Here
9.6%
US
3.2%
UT
2.6%
Salt lake
2.0%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility7.6%
Better than Avg
Here
7.6%
US
14.4%
UT
12.1%
Salt lake
10.9%
😔

Residents with depression symptoms

↓ Lower is better
This Facility17.4%
Mixed vs Avgs
Here
17.4%
US
12.1%
UT
16.5%
Salt lake
23.2%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🩹

Residents with pressure sores (bedsores)

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
4.9%
UT
4.1%
Salt lake
3.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility83.1%
Mixed vs Avgs
Here
83.1%
US
81.8%
UT
93.8%
Salt lake
94.8%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility85.7%
Mixed vs Avgs
Here
85.7%
US
79.7%
UT
91.0%
Salt lake
92.0%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
UT
0.8%
Salt lake
0.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

6deficiencies
1penalties
Near state avg (9.1)
1 complaint-triggered
$17,940 in fines

Monument Healthcare has recurring safety and care issues spanning three surveys, with families filing complaints about resident protection. The facility shows persistent problems with accident prevention and safety hazards, medication management, and infection control across all inspection periods from 2019 to 2024. While the facility corrects deficiencies when cited, the pattern of repeated violations in critical areas like safety supervision and pharmaceutical services suggests ongoing operational challenges that families should carefully consider.

Apr 4, 2024Routine
5
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0584Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

0609Potential for harm · PatternResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Apr 4, 2024Complaint
1
0600Potential for harm · IsolatedResolved (past non-compliance)

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

May 5, 2022Routine
13
0689Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0692Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

0550Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0656Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0744Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

0867Potential for harm · PatternCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0887Potential for harm · PatternCorrected

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

0688Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

0756Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0770Potential for harm · IsolatedCorrected

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Dec 5, 2019Routine
10
0725Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

0604Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0676Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0744Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0004Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Federal Penalties

Fine

Apr 4, 2024

$17,940

Ownership & Operations

Who Operates This Facility

Owner / Operator

Monument Healthcare Cottonwood Creek

Organization Type

for profit

Chain Affiliation

Chain Name

Monument Health Group

Chain Size

11 facilities nationwide

Chain avg rating: 3.3/5 · Rank 13 of 14 (Worst)

Ownership & Management

Key personnel

Murray, BrianOfficer / DirectorGunnison Valley HospitalManagerHealth Group Management LLCManagerMonument Health Group LLCManagerClawson, TravisManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

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