Inspection Reports for Mt. Olympus Rehabilitation Center
2200 East 3300 South, Salt Lake City, UT, 84109
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
19.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
151% worse than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
68 residents
Based on a June 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 24, 2025
Visit Reason
The inspection was conducted following a complaint investigation triggered by an incident where a resident was dropped from a Hoyer lift due to use of an unapproved transfer sheet instead of an approved Hoyer sling, resulting in the resident's death.
Complaint Details
The complaint investigation was substantiated. Immediate Jeopardy (IJ) was verbally given to the Administrator at 11:00 AM on the day of the incident. The resident was admitted on the day of the incident, transferred using a non-approved transfer sheet sling which failed, causing the resident to fall and die. Multiple interviews with nursing staff, CNAs, transport driver, and administration confirmed the incident and lack of proper training and equipment use. The facility implemented an abatement plan including staff training, equipment audits, and policy updates. The IJ abatement was verified onsite by the survey team.
Findings
The facility failed to ensure resident safety by using an unapproved transfer sheet instead of a proper Hoyer sling during a resident transfer, leading to the resident falling and dying. Additionally, nursing staff lacked proper training and competency in the use of Hoyer lifts and slings. Immediate jeopardy was identified and an abatement plan was implemented including staff training, equipment audits, and updated policies.
Deficiencies (2)
Failure to ensure the resident environment was free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident being dropped from a Hoyer lift and dying.
Failure to ensure nurses and nurse aides had appropriate competencies to care for residents, specifically lack of education on proper use of Hoyer lifts and approved slings.
Report Facts
Resident weight: 325
Number of residents using Hoyer lifts: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Witnessed resident fall and initiated CPR; provided detailed interview about the incident |
| CNA 1 | Certified Nursing Assistant | Assisted with resident transfer using unapproved sling; provided statements to police and interviews |
| CNA 2 | Certified Nursing Assistant | Assisted with resident transfer; involved in incident and provided interview |
| CNA 4 | Certified Nursing Assistant | Provided information about Hoyer sling storage and use; interviewed about training |
| CNA 5 | Certified Nursing Assistant | Reported no hands-on training on Hoyer lifts and slings; provided interview |
| CNA 6 | Certified Nursing Assistant | Reported prior training on Hoyer lift but unsure about recent training |
| CNA 7 | Certified Nursing Assistant | Reported recent training on Hoyer lift policies |
| CNA 8 | Certified Nursing Assistant | Reported recent hands-on training and visual confirmation of new Hoyer slings |
| ADM 1 | Administrator | Involved in incident response; implemented abatement plan; interviewed |
| DON | Director of Nursing | Involved in incident response; implemented abatement plan; interviewed |
| ADON | Assistant Director of Nursing | Involved in incident response; implemented abatement plan; interviewed |
Inspection Report
Census: 68
Deficiencies: 22
Date: 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.
Deficiencies (22)
Failure to properly assess 3 residents for safe self-administration of medications and lack of care plans and documentation for self-administration.
Failure to ensure residents' rights to formulate advance directives and obtain proper documentation and signatures.
Failure to ensure one resident was free from physical abuse by another resident; substantiated resident-to-resident abuse.
Failure to notify the State Long Term Care Ombudsman of transfers and discharges for 3 residents.
Failure to notify residents or representatives of the bed hold policy upon hospitalization or therapeutic leave for 4 residents.
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.
Failure to ensure IV medications were administered by qualified staff with IV certification for one resident.
Failure to complete discharge summaries with required elements for 5 discharged residents.
Failure to provide appropriate assistance with eating including proper positioning and adaptive equipment for one resident.
Failure to ensure follow-up neurology appointment was scheduled for one resident after hospital discharge.
Failure to provide adequate supervision and interventions to prevent elopements for multiple residents; Immediate Jeopardy identified and removed.
Failure to obtain informed consent and assess risk of entrapment prior to bed rail installation for multiple residents.
Failure to complete annual performance reviews for 3 nurse aides.
Medication error rate exceeded 5% due to insulin pen not primed prior to administration and wrong aspirin formulation administered.
Failure to provide or obtain routine/follow-up dental services for one resident.
Failure to ensure food was properly covered, labeled, dated, not expired, and served at proper temperature in multiple kitchen and resident areas.
Failure to maintain complete and accurate documentation in the medical record for one resident related to hospital transfer and incident.
Failure to obtain and maintain hospice documentation and coordinate hospice care for one resident.
Failure to implement infection prevention and control program including enhanced barrier precautions, water management program, proper PPE disposal, and hand hygiene.
Failure to follow antibiotic stewardship protocols including initiation criteria and repeat testing for one resident.
Failure to provide education and obtain consent for pneumococcal immunization for two residents.
Failure to provide effective communication training for 3 staff members.
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 |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: May 9, 2024
Visit Reason
The inspection was conducted based on complaint investigations regarding failure to notify the Ombudsman of resident transfers, delayed care plan development, inadequate supervision to prevent elopements, improper medication administration, and infection control issues.
Complaint Details
The complaint investigation revealed multiple issues including failure to notify the Ombudsman of resident hospital transfers, delayed care plan development, inadequate supervision leading to resident elopements, improper medication administration, and infection control violations.
Findings
The facility failed to notify the Ombudsman of resident transfers to hospital, delayed baseline and comprehensive care plan development for multiple residents, did not provide adequate supervision to prevent elopements for several residents including lack of physician orders for wanderguards, administered blood pressure medications outside ordered parameters, improperly handled narcotics, and failed to follow infection control protocols during medication administration.
Deficiencies (7)
Failure to notify the Office of the State Long-Term Care Ombudsman of resident transfer or discharge in writing.
Failure to develop and implement a baseline care plan within 48 hours of admission for 2 residents.
Failure to develop complete care plans within 7 days of comprehensive assessment and revise by interdisciplinary team for 2 residents.
Failure to provide adequate supervision and assistance devices to prevent accidents and elopements for 4 residents; wanderguards placed without physician orders.
Blood pressure medication administered outside of physician ordered parameters for 1 resident.
Narcotics repackaged into medication cards without proper labeling and wasting procedures.
Failure to follow infection prevention and control protocols during medication administration; staff touched medications with bare hands and medications were dropped and administered.
Report Facts
Residents sampled: 38
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Interviewed regarding blood pressure medication administration |
| Registered Nurse 2 | Registered Nurse | Observed and interviewed regarding medication administration and narcotic handling |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan development, medication administration, wanderguard use, and infection control |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Interviewed regarding supervision of resident who eloped |
| Resident Advocate | Interviewed regarding notification to Ombudsman and resident elopements |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: May 9, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify the Ombudsman of resident transfers, delayed care plan development, inadequate supervision to prevent elopements, improper medication administration, and infection control issues.
Complaint Details
The complaint investigation revealed substantiated deficiencies including failure to notify Ombudsman of resident hospital transfers, delayed care plan development, inadequate supervision leading to elopements, improper medication administration, and infection control breaches.
Findings
The facility failed to notify the Ombudsman of resident transfers to hospital, delayed baseline and comprehensive care plan development for multiple residents, did not provide adequate supervision to prevent elopements for several residents including lack of physician orders for wanderguards, administered blood pressure medications outside ordered parameters, improperly handled narcotics, and failed to follow infection control protocols during medication administration.
Deficiencies (7)
Failure to notify the Office of the State Long-Term Care Ombudsman of resident transfer or discharge in writing.
Failure to develop and implement a baseline care plan within 48 hours of admission for 2 residents.
Failure to develop complete care plans within 7 days of comprehensive assessment and revise by interdisciplinary team for 2 residents.
Failure to provide adequate supervision and assistance devices to prevent accidents and elopements for 4 residents; wanderguards placed without physician orders.
Failure to ensure resident's drug regimen was free from unnecessary drugs; blood pressure medications administered outside physician ordered parameters.
Failure to label all drugs and biologicals according to professional principles; narcotics repackaged into medication cards improperly.
Failure to implement infection prevention and control program; staff observed touching medications with bare hands and medications dropped then administered.
Report Facts
Sample residents: 38
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 4
Residents affected: 1
Medication administration errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Discussed blood pressure medication administration and parameters |
| RN 2 | Registered Nurse | Observed touching medications with bare hands during medication pass |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding care plan delays, medication administration, wanderguard use, and infection control |
| CNA 1 | Certified Nursing Assistant | Left resident unattended leading to elopement |
| Resident Advocate | Interviewed regarding failure to notify Ombudsman and resident elopements |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Feb 14, 2023
Visit Reason
The inspection was conducted based on complaints and allegations regarding the facility's failure to maintain a clean and safe environment, timely reporting of abuse and neglect, proper care for residents' activities of daily living, and infection prevention and control.
Complaint Details
The investigation was complaint-driven, focusing on allegations of unclean environment, failure to report abuse and neglect, inadequate assistance with activities of daily living, and infection control breaches. Specific complaints included unreported resident elopement, unreported abuse allegations, and unsafe oxygen tubing practices.
Findings
The facility was found deficient in maintaining a clean, comfortable environment for residents, timely reporting and investigating allegations of abuse and neglect, providing adequate assistance with activities of daily living such as bathing, and implementing an effective infection prevention and control program. Specific incidents included unclean resident rooms and equipment, failure to report a resident's elopement and abuse allegations to the State Survey Agency, inadequate showering schedules for dependent residents, and unsafe handling of oxygen tubing.
Deficiencies (5)
Facility did not provide a clean, comfortable homelike environment; resident rooms and equipment were dirty and furniture was broken.
Failure to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities.
Failure to respond appropriately to all alleged violations; lack of evidence of thorough investigations and reporting to State Survey Agency within 5 working days.
Failure to provide care and assistance to perform activities of daily living; dependent residents did not receive showers or bathing assistance timely and as scheduled.
Failure to provide and implement an infection prevention and control program; oxygen tubing was found on the floor and reused by resident.
Report Facts
Residents sampled: 41
Residents affected by unclean environment: 5
Residents affected by failure to report abuse: 4
Residents affected by failure to investigate abuse: 3
Residents affected by inadequate ADL care: 2
Residents affected by infection control breach: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator (ADM) | Facility Administrator and Abuse Coordinator | Provided multiple interviews regarding abuse reporting, investigations, and incident management. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding incident reporting and investigation responsibilities. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding abuse investigations, shower schedules, and infection control. |
| Housekeeper (HK) 1 | Housekeeper | Interviewed about cleaning schedules and staffing. |
| Resident Advocate (RA) | Resident Advocate | Interviewed about housekeeping staffing and cleaning responsibilities. |
| Nursing Assistant (NA) 1 | Nursing Assistant | Interviewed about shower scheduling and documentation. |
| Certified Nurse Assistant (CNA) 2 | Certified Nurse Assistant | Interviewed about shower refusals and oxygen tubing practices. |
| Certified Nurse Assistant (CNA) 3 | Certified Nurse Assistant | Interviewed about oxygen tubing infection control practices. |
| Registered Nurse (RN) 2 | Registered Nurse | Interviewed about shower procedures and documentation. |
| Registered Nurse (RN) 4 | Registered Nurse | Interviewed about abuse reporting and resident 3's behavior. |
| Registered Nurse (RN) 1 | Registered Nurse | Interviewed about resident 3's mental status and abuse reporting. |
| Nursing Assistant (NA) 3 | Nursing Assistant | Interviewed about shower schedules and resident assistance. |
| Certified Nurse Assistant (CNA) 6 | Certified Nurse Assistant | Interviewed about oxygen tubing change procedures. |
| Nursing Assistant (NA) 7 | Certified Nurse Assistant | Observed picking up oxygen tubing from floor and offering it to resident. |
Inspection Report
Annual Inspection
Census: 41
Deficiencies: 18
Date: Feb 14, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for a nursing home facility.
Findings
The facility was found deficient in multiple areas including medication self-administration evaluations, timely physician notification of critical blood sugars, maintenance of a clean and safe environment, abuse prevention and investigation, accurate assessments and care planning, medication administration per physician orders, infection control, and proper documentation of laboratory and diagnostic reports.
Deficiencies (18)
Facility did not ensure resident right to self-administer medications was determined by interdisciplinary team as clinically appropriate and safe for 2 residents.
Facility nursing staff did not notify provider when resident's blood sugar was greater than indicated amount per physician order for 1 resident.
Facility did not provide a clean, comfortable homelike environment; resident rooms and equipment were dirty and furniture broken for 5 residents.
Facility did not ensure residents were free from abuse, neglect, and misappropriation of property; sexual abuse incidents not fully investigated or reported for 3 residents.
Facility failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities for 4 residents including a missing resident and a resident with burns from oxygen ignition.
Facility failed to maintain medical records that were complete, accurate, accessible, and organized; blood pressure readings inaccurately documented, missing hospital and ER documentation for 3 residents.
Facility failed to coordinate assessments with pre-admission screening and resident review (PASARR) program for 1 resident who required PASARR Level II evaluation.
Facility did not develop and implement baseline care plans within 48 hours of admission that included instructions needed to provide effective and person-centered care for 3 residents.
Facility did not develop and implement comprehensive person-centered care plans addressing pain, falls, smoking, and ADL assistance for 9 residents.
Facility failed to provide necessary behavioral health care and services to a resident who attempted suicide and had multiple recommendations for behavioral health services prior to the incident.
Facility failed to ensure residents received medications per physician ordered parameters; medications were administered or held outside parameters for 4 residents.
Facility did not file dated laboratory reports with name and address of testing laboratory in resident records for 3 residents; sensitivity report missing for one resident, troponin and CK report missing for one resident, influenza nasal swab report missing for one resident.
Facility did not provide or obtain routine dental services; a resident stated dentures did not fit and needed adjustment, and dental appointment revealed need for realignment.
Facility employed a nurse with a suspended license who provided patient care and did not follow license restrictions.
Facility failed to maintain medical records that were complete, accurate, accessible, and organized; multiple blood pressure readings inaccurately documented as taken on left arm with AV fistula, missing hospital documentation for ER visit and tests for one resident.
Facility failed to provide necessary services to maintain good nutrition, grooming, and personal and oral hygiene; two dependent residents did not receive showers or bathing assistance in a timely manner and according to schedule.
Facility failed to ensure resident environment remained free of accident hazards and provide adequate supervision to prevent accidents; a resident received second degree burns when oxygen cannula ignited while smoking unsupervised; multiple residents requiring supervision while smoking were observed smoking without staff present; a resident sustained a skin tear when not secured in transportation van.
Facility failed to ensure that residents received treatment and care in accordance with professional standards and care plan; hospice communication notes were not contained within resident's medical records and staff reported difficulty with communication between hospice providers.
Report Facts
Residents sampled: 41
Critical blood sugar readings: 20
Shower refusals: 6
Shower received: 4
Lorazepam PRN order duration: 19
Lorazepam doses: 9
Shower frequency: 3
Resident 133 showers: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| PCC | Patient Care Coordinator | Nurse with suspended license who provided care to resident 47 and was restricted from wound care |
| LPN 4 | Licensed Practical Nurse | Discussed medication administration and parameters for resident 11 and 32 |
| RN 1 | Registered Nurse | Discussed blood sugar monitoring and physician notification for resident 47 |
| DON | Director of Nursing | Multiple interviews regarding care plans, medication administration, hospice communication, and abuse investigations |
| ADM | Administrator | Discussed abuse reporting, nurse staffing, and incident investigations |
| RA | Resident Advocate | Discussed social worker workload, abuse investigations, and dental services |
| LPN 3 | Licensed Practical Nurse | Discussed dental services and smoking supervision |
| RN 2 | Registered Nurse | Discussed shower documentation and staff education |
| CNA 2 | Certified Nursing Assistant | Discussed shower refusals and documentation |
| CNA 3 | Certified Nursing Assistant | Discussed shower refusals and oxygen tubing infection risk |
| WCN | Wound Care Nurse | Discussed wound care and resident 47 incident |
| TD | Transportation Driver | Discussed resident 47 fall during transport and safety concerns |
Inspection Report
Complaint Investigation
Deficiencies: 18
Date: Jul 15, 2021
Visit Reason
The inspection was conducted based on complaints and allegations related to resident rights, notice of Medicare non-coverage, safe environment, abuse and neglect, transfer and discharge procedures, care planning, medication management, infection control, food quality, and other regulatory compliance issues.
Complaint Details
The complaint investigation revealed multiple deficiencies related to resident rights, abuse and neglect, care planning, medication management, infection control, food safety, and environmental concerns. Specific substantiation status was not explicitly stated in the report.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignified existence and self-determination, failure to provide notice of Medicare non-coverage timely, unsafe and unclean environment, failure to protect residents from abuse and neglect, inadequate transfer documentation, incomplete care plans, inappropriate medication administration, inadequate infection control practices, poor food quality and temperature control, and failure to maintain complete medical records including hospice documentation.
Deficiencies (18)
Failure to honor residents' rights to a dignified existence and self-determination, specifically regarding residents not being allowed to go to the store during COVID-19 restrictions.
Failure to provide timely notice of Medicare non-coverage to residents.
Facility environment was not safe, clean, comfortable or homelike; floors were sticky, carpets stained, bathrooms had missing baseboards, fans soiled, wheelchairs unclean, and debris present in resident rooms.
Failure to protect residents from abuse and neglect, including resident-to-resident altercations that were not properly addressed or documented.
Failure to ensure adequate transfer documentation was provided to receiving healthcare institutions, including practitioner contact information, advance directives, and discharge summaries.
Failure to develop and implement baseline care plans that include instructions for effective and person-centered care, including assistance with eating, therapy, dietary needs, and behavioral health interventions.
Failure to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes, including care plans for smoking safety, resident altercations, urinary tract infections, falls, behavioral health, and CPAP machine use.
Failure to provide treatment and care according to orders, resident preferences and goals, including failure to prevent alcohol relapse and delay in treatment of urosepsis.
Failure to maintain a safe environment free from accident hazards and provide adequate supervision to prevent accidents, including inadequate supervision of residents smoking and intoxicated residents leaving the facility unsupervised.
Failure to provide appropriate care for residents with urinary incontinence, including failure to provide timely incontinence care and changing of briefs.
Failure to provide safe and appropriate respiratory care, including failure to provide and maintain CPAP machine for a resident with obstructive sleep apnea.
Failure to maintain complete, accurate, accessible, and systematically organized medical records, including missing hospice notes, wound documentation, mental health visit notes, and shower sheets with skin assessments.
Failure to arrange for provision of hospice services with a written agreement signed by authorized representatives of hospice and facility, including communication processes to ensure resident needs are met 24 hours per day.
Failure to ensure each resident's drug regimen was free from unnecessary drugs, including duplicate therapy, lack of monitoring, and PRN orders without documented rationale for extended use.
Failure to ensure drugs and biologicals were labeled in accordance with professional principles, stored under proper temperature controls, and included expiration dates; multi-use vials lacked open dates and expired medications were available for use.
Failure to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures; residents complained of poor food quality and food was served uncovered and stored improperly.
Failure to provide and implement an infection prevention and control program, including improper use of PPE, failure to change gowns between residents, failure to bag and separate meal trays from isolation rooms, improper cleaning of blood pressure cuffs, and staff wearing masks improperly.
Failure to have adequate outside ventilation by window or mechanical means; facility had pervasive urine odors throughout.
Report Facts
Residents sampled: 40
Deficiencies cited: 19
Medication doses administered: 21
Medication doses administered: 8
Medication doses administered: 16
Medication doses administered: 2.5
Medication doses administered: 10
Medication doses administered: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Mentioned in relation to catheter care and resident 40's urologist consultation |
| LPN 2 | Licensed Practical Nurse | Mentioned in relation to abuse incident investigation and hospice communication |
| LPN 3 | Licensed Practical Nurse | Mentioned in relation to resident 23's wheelchair evaluation and bowel/bladder care |
| LPN 4 | Licensed Practical Nurse | Mentioned in relation to CPAP care and skin assessment |
| LPN 5 | Licensed Practical Nurse | Mentioned in relation to cleaning blood pressure cuff and edema monitoring |
| RN 1 | Registered Nurse | Mentioned in relation to resident 51 interview, medication administration, infection control, and hospice communication |
| RN 2 | Registered Nurse | Mentioned in relation to abuse incident investigation |
| RN 10 | Certified Nursing Assistant | Mentioned in relation to resident 78 elopement incident |
| CNA 3 | Certified Nursing Assistant | Mentioned in relation to infection control and CPAP machine care |
| CNA 4 | Certified Nursing Assistant | Mentioned in relation to infection control and CPAP machine care |
| CNA 5 | Certified Nursing Assistant | Mentioned in relation to incontinence care and food delivery |
| CNA 6 | Certified Nursing Assistant | Mentioned in relation to CPAP machine care |
| CNA 7 | Certified Nursing Assistant | Mentioned in relation to infection control and meal tray handling |
| CNA 9 | Certified Nursing Assistant | Mentioned in relation to incontinence care |
| DON | Director of Nursing | Mentioned extensively in relation to multiple findings including abuse, medication management, infection control, care planning, and hospice communication |
| Administrator | Facility Administrator | Mentioned in relation to infection control, food service, and facility management |
| LCSW | Licensed Clinical Social Worker | Mentioned in relation to abuse investigations and behavioral health services |
| PCC | Personal Care Coordinator | Mentioned in relation to hospice communication and incontinence care |
| DM | Dietary Manager | Mentioned in relation to food quality and kitchen sanitation |
| WN | Wound Nurse | Mentioned in relation to skin assessments and wound care |
| GO | Grievance Officer | Mentioned in relation to abuse investigations and hospice communication |
| HN | Hospice Nurse | Mentioned in relation to facility entry without screening |
| SLP 1 | Speech Language Pathologist | Mentioned in relation to resident 228's eating assistance |
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