Inspection Reports for Mt. Olympus Rehabilitation Center
2200 East 3300 South, UT, 84109
Back to Facility ProfileDeficiencies per Year
24
18
12
6
0
Severe
Moderate
Inspection Report
Census: 68
Deficiencies: 22
Jun 28, 2024
Visit Reason
The Centers for Medicare and Medicaid Services conducted a comparative Federal Monitoring Survey (FMS) from 6/24-6/28/24 to assess compliance with federal regulations.
Findings
The survey identified multiple deficiencies including failure to properly assess residents for self-administration of medications, incomplete advance directive documentation, substantiated resident-to-resident abuse, failure to notify the Ombudsman of transfers and discharges, failure to provide bed hold policy notifications, incomplete comprehensive care plans, unqualified staff administering IV medications, incomplete discharge summaries, inadequate assistance with activities of daily living, failure to schedule follow-up appointments, inadequate supervision to prevent elopements, food safety violations, incomplete medical record documentation, incomplete hospice documentation, infection control deficiencies, antibiotic stewardship failures, incomplete immunization documentation, lack of communication training for staff, and other regulatory noncompliances.
Severity Breakdown
SS=F: 2
SS=K: 1
SS=E: 5
SS=D: 13
Deficiencies (22)
| Description | Severity |
|---|---|
| Failure to properly assess 3 residents for safe self-administration of medications and lack of care plans and documentation for self-administration. | SS=D |
| Failure to ensure residents' rights to formulate advance directives and obtain proper documentation and signatures. | SS=D |
| Failure to ensure one resident was free from physical abuse by another resident; substantiated resident-to-resident abuse. | SS=D |
| Failure to notify the State Long Term Care Ombudsman of transfers and discharges for 3 residents. | SS=D |
| Failure to notify residents or representatives of the bed hold policy upon hospitalization or therapeutic leave for 4 residents. | SS=E |
| Failure to develop and implement comprehensive care plans including psychotropic medications, behaviors, and PASRR recommendations for one resident; failure to invite one resident to participate in care planning. | SS=D |
| Failure to ensure IV medications were administered by qualified staff with IV certification for one resident. | SS=E |
| Failure to complete discharge summaries with required elements for 5 discharged residents. | SS=E |
| Failure to provide appropriate assistance with eating including proper positioning and adaptive equipment for one resident. | SS=D |
| Failure to ensure follow-up neurology appointment was scheduled for one resident after hospital discharge. | SS=D |
| Failure to provide adequate supervision and interventions to prevent elopements for multiple residents; Immediate Jeopardy identified and removed. | SS=K |
| Failure to obtain informed consent and assess risk of entrapment prior to bed rail installation for multiple residents. | SS=E |
| Failure to complete annual performance reviews for 3 nurse aides. | SS=D |
| Medication error rate exceeded 5% due to insulin pen not primed prior to administration and wrong aspirin formulation administered. | SS=D |
| Failure to provide or obtain routine/follow-up dental services for one resident. | SS=D |
| Failure to ensure food was properly covered, labeled, dated, not expired, and served at proper temperature in multiple kitchen and resident areas. | SS=F |
| Failure to maintain complete and accurate documentation in the medical record for one resident related to hospital transfer and incident. | SS=D |
| Failure to obtain and maintain hospice documentation and coordinate hospice care for one resident. | SS=D |
| Failure to implement infection prevention and control program including enhanced barrier precautions, water management program, proper PPE disposal, and hand hygiene. | SS=F |
| Failure to follow antibiotic stewardship protocols including initiation criteria and repeat testing for one resident. | SS=D |
| Failure to provide education and obtain consent for pneumococcal immunization for two residents. | SS=D |
| Failure to provide effective communication training for 3 staff members. | SS=D |
Report Facts
Census: 68
Medication error rate: 6.06
Residents at risk for elopement: 19
Residents reviewed for advance directives: 31
Residents reviewed for medication administration: 6
Residents reviewed for discharge: 8
Residents reviewed for bed rails: 4
Nurse Aides reviewed for performance evaluation: 3
Residents reviewed for dental care: 2
Residents reviewed for immunization: 5
Residents reviewed for antibiotic use: 2
Residents reviewed for communication training: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN2 | Registered Nurse | Administered insulin pen without priming; did not attend communication training |
| LPN2 | Licensed Practical Nurse | Administered IV medications without IV certification; did not attend communication training |
| RN1 | Registered Nurse | Administered wrong aspirin formulation |
| NA14 | Nurse Aide | Did not attend communication training |
| DON | Director of Nursing | Named in multiple findings including failure to ensure follow-up appointments, incomplete documentation, infection control, and staff training |
| RA | Resident Advocate | Named in findings related to advance directives, discharge notification, elopement, dental care, and hospice coordination |
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