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)
19.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
144% worse than Utah average
Utah average: 7.9 deficiencies/year
Deficiencies per year
32
24
16
8
0
Occupancy
Latest occupancy rate
68% occupied
Based on a June 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Enforcement
Deficiencies: 2
Date: Oct 24, 2025
Visit Reason
The inspection was conducted due to an immediate jeopardy incident where a resident was dropped from a Hoyer lift using an unapproved transfer sheet instead of an approved sling, resulting in the resident's death. The visit aimed to assess compliance with safety and nursing competency regulations related to accident prevention and proper use of lifting equipment.
Findings
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or competent nursing staff training on the proper use of Hoyer lifts and slings. A resident was fatally injured when the straps of a non-approved transfer sheet broke during transfer. The facility implemented an abatement plan including staff training, equipment audits, and updated policies to prevent recurrence.
Deficiencies (2)
F689: The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in a resident being dropped from a Hoyer lift and dying due to use of an unapproved transfer sheet instead of a proper sling.
F726: The facility failed to ensure nurses and nurse aides had appropriate competencies and skills to safely use Hoyer lifts and approved slings, contributing to a resident being dropped from a lift and dying.
Report Facts
Resident weight: 325
Number of residents using Hoyer lifts: 5
Years employed: 15
Years employed: 9
Years employed: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Witnessed resident fall and initiated CPR |
| CNA 1 | Certified Nursing Assistant | Assisted with resident transfer using unapproved sling |
| CNA 2 | Certified Nursing Assistant | Assisted with resident transfer using unapproved sling |
| ADM 1 | Administrator | Involved in immediate jeopardy notification and policy updates |
| DON | Director of Nursing | Involved in immediate jeopardy notification, training, and policy updates |
| ADON | Assistant Director of Nursing | Involved in immediate jeopardy notification and training |
| Regional Nurse Consultant | Regional Nurse Consultant | Provided education and training on proper use of Hoyer lifts and slings |
| CNA 4 | Certified Nursing Assistant | Provided information on sling use and facility practices |
| CNA 5 | Certified Nursing Assistant | Reported lack of hands-on training on Hoyer lifts and slings |
| CNA 6 | Certified Nursing Assistant | Reported prior training on Hoyer lifts but unsure of 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 slings |
Inspection Report
Routine
Census: 68
Deficiencies: 22
Date: Jun 28, 2024
Visit Reason
The facility underwent a Federal Monitoring Survey from 6/24 to 6/28/2024 to assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies including failures in medication self-administration assessments, advance directive documentation, abuse prevention, transfer/discharge notifications, bed hold policy notifications, comprehensive care planning, qualified personnel for IV medication administration, discharge summaries, activities of daily living assistance, quality of care including follow-up appointments, elopement prevention, smoking safety, food safety, resident record completeness, hospice care coordination, infection prevention and control, antibiotic stewardship, immunizations, communication training, and medication administration accuracy.
Deficiencies (22)
F554 Resident Self-Administration Medications: The facility failed to ensure 3 residents were appropriately assessed and had care plans for self-administering medications, including proper documentation and labeling of medications.
F578 Advance Directives: The facility failed to obtain or document advance directive authority and signatures for 3 residents, including failure to contact guardians and document refusals.
F600 Abuse Prevention: The facility failed to prevent physical abuse by another resident for 1 resident, with substantiated resident-to-resident abuse.
F623 Transfer/Discharge Notice: The facility failed to notify the State Long-Term Care Ombudsman of transfers or discharges for 3 residents.
F625 Bed Hold Policy Notice: The facility failed to provide written bed hold policy information to 4 residents upon hospitalization or therapeutic leave.
F656 Comprehensive Care Plan: The facility failed to develop and implement a comprehensive care plan including psychotropic medications, behaviors, and PASRR recommendations for 1 resident.
F657 Care Plan Timing and Revision: The facility failed to ensure 1 resident was invited to participate in care plan meetings quarterly as required.
F659 Qualified Persons: The facility failed to ensure IV medications were administered by licensed nurses with IV certification for 1 resident.
F661 Discharge Summary: The facility failed to complete discharge summaries with required content for 5 residents discharged or transferred.
F676 Activities of Daily Living: The facility failed to provide proper positioning and adaptive equipment during meals for 1 resident to maintain independent eating.
F684 Quality of Care: The facility failed to ensure follow-up neurology appointment was scheduled for 1 resident after hospitalization for seizure.
F689 Free of Accident Hazards: The facility failed to provide adequate supervision and care planning to prevent elopements for 6 residents, and failed to ensure safe smoking practices for 2 residents.
F790 Dental Services: The facility failed to ensure routine dental follow-up services were provided for 1 resident with dental concerns.
F812 Food Safety: The facility failed to ensure food was properly covered, labeled, dated, free of expired items, and nutritional shakes were served at proper temperatures in multiple kitchen and resident unit refrigerators and freezers.
F842 Resident Records: The facility failed to maintain complete and accurate documentation of a resident's hospital transfer and injury in the medical record.
F849 Hospice Services: The facility failed to obtain and maintain complete hospice documentation in the resident's medical record to coordinate care.
F880 Infection Prevention and Control: The facility failed to implement enhanced barrier precautions, maintain a water management program, ensure proper PPE disposal, and ensure hand hygiene during resident care.
F881 Antibiotic Stewardship: The facility failed to follow antibiotic initiation protocols and failed to repeat contaminated urine testing before antibiotic administration for 1 resident.
F883 Immunizations: The facility failed to provide education and obtain informed consent for pneumococcal immunization for 2 residents and failed to administer the vaccine when consented.
F941 Communication Training: The facility failed to ensure 3 of 5 staff completed effective communication training.
Medication Administration: The facility failed to prime insulin pens prior to administration and administered incorrect aspirin formulation for 2 residents.
Bed Rails: The facility failed to obtain informed consent and assess entrapment risk prior to installation of bed rails for 4 residents.
Report Facts
Residents at risk for elopement: 19
Medication error rate: 6.06
Residents reviewed for medication administration: 6
Residents reviewed for bed rails: 4
Residents reviewed for nurse aide performance: 3
Residents reviewed for immunization: 5
Residents reviewed for dental care: 2
Residents reviewed for infection control: 3
Residents reviewed for antibiotic use: 2
Residents reviewed for communication training: 5
Residents reviewed for discharge summaries: 8
Residents reviewed for elopement: 9
Residents reviewed for smoking safety: 5
Residents reviewed for activities of daily living: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN2 | Registered Nurse | Medication administration and communication training |
| LPN2 | Licensed Practical Nurse | Medication administration, elopement training, communication training |
| NA14 | Nurse Aide | Communication training |
| Director of Nursing | Director of Nursing | Oversight of multiple deficiencies and corrective actions |
| Resident Advocate | Resident Advocate | Involved in advance directives, discharge notifications, dental care coordination, elopement prevention |
| Administrator | Administrator | Oversight and corrective action implementation |
| Infection Preventionist | Infection Preventionist | Infection control program and antibiotic stewardship |
| Dietary Supervisor | Dietary Supervisor | Food safety and storage |
| Regional Nurse Consultant | Regional Nurse Consultant | Staff education and quality assurance |
| RN3 | Registered Nurse | Elopement and transfer documentation |
| NA3 | Nurse Aide | Smoking supervision |
| LPN3 | Licensed Practical Nurse | Elopement investigation |
| RN1 | Registered Nurse | Medication administration observation |
| NA2 | Nurse Aide | Smoking supervision |
| NA5 | Nurse Aide | Infection control observation |
| NA6 | Nurse Aide | Infection control observation |
| NA8 | Nurse Aide | Infection control observation |
| RN4 | Registered Nurse | Care of hospice resident and infection control |
| LPN1 | Licensed Practical Nurse | Bed rail use |
| NA1 | Nurse Aide | Bed rail use |
| NA15 | Nurse Aide | Infection control training |
| Housekeeper 1 | Housekeeper | Infection control training |
| Physical Therapy Assistant | Physical Therapy Assistant | Infection control training and resident positioning |
| Consulting Pharmacist | Consulting Pharmacist | Medication administration review |
Inspection Report
Routine
Deficiencies: 7
Date: May 9, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements for nursing home care, including resident care plans, medication administration, safety, and infection control.
Findings
The facility was found deficient in timely notification of resident transfers to the Ombudsman, delayed development of baseline and comprehensive care plans, inadequate supervision to prevent elopements, improper medication administration outside physician parameters, improper narcotic labeling and handling, and failure to maintain infection prevention practices during medication administration.
Deficiencies (7)
F0623: The facility failed to notify the Office of the State Long-Term Care Ombudsman in writing of a resident's transfer or discharge to the hospital for 1 of 38 sampled residents.
F0655: The facility did not develop and implement a baseline care plan within 48 hours of admission for 2 of 38 sampled residents, delaying care planning by 7 days.
F0657: The facility failed to develop complete care plans within 7 days of comprehensive assessments and did not revise them by an interdisciplinary team for 2 of 38 sampled residents.
F0689: The facility did not provide adequate supervision or interventions to prevent elopements for 4 of 38 sampled residents, including use of wanderguards without physician orders and multiple elopements without additional safety measures.
F0757: The facility administered blood pressure medications outside of physician-ordered parameters for 1 of 38 sampled residents, failing to hold medications when systolic blood pressure was below ordered limits.
F0761: The facility did not label all drugs and biologicals according to professional principles and improperly repackaged narcotics into medication cards.
F0880: The facility failed to maintain infection prevention practices during medication administration, including a nurse touching medications with bare hands and administering medications dropped on the medication cart.
Report Facts
Sampled residents: 38
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Interviewed regarding blood pressure medication administration and parameters |
| Registered Nurse 2 | Registered Nurse | Observed and interviewed regarding medication administration and infection control failures |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan development, medication administration policies, narcotic handling, and infection control |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Interviewed regarding one-on-one supervision failure during resident elopement |
| Resident Advocate | Interviewed regarding notification failures and resident elopement incidents |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Feb 14, 2023
Visit Reason
The inspection was conducted to investigate multiple complaints including the facility's failure to maintain a clean and safe environment, failure to timely report suspected abuse or neglect, failure to investigate and report abuse allegations, failure to provide adequate assistance with activities of daily living, and failure to maintain an infection prevention and control program.
Complaint Details
The investigation was complaint-driven, focusing on allegations of unclean environment, failure to report abuse and neglect, failure to investigate abuse allegations, inadequate assistance with ADLs, and infection control breaches. Substantiation status is not explicitly stated.
Findings
The facility was found to have multiple deficiencies including unclean resident rooms and equipment, failure to report and investigate abuse and neglect incidents timely, inadequate assistance with resident bathing and hygiene, and unsafe infection control practices related to oxygen tubing. Several residents were affected by these issues.
Deficiencies (5)
F 0584: The facility failed to provide a clean, comfortable, and homelike environment. Resident rooms and equipment were observed dirty or broken for 5 of 41 sampled residents.
F 0609: The facility failed to timely report suspected abuse, neglect, or theft and failed to investigate and report abuse allegations for 4 of 41 sampled residents.
F 0610: The facility failed to respond appropriately to all alleged violations of abuse, neglect, or mistreatment for 3 of 41 sampled residents, lacking evidence of thorough investigations and timely reporting.
F 0677: The facility failed to provide necessary assistance with activities of daily living, including bathing, for 2 of 41 sampled residents, resulting in missed or delayed showers.
F 0880: The facility failed to maintain an infection prevention and control program by allowing oxygen tubing to be used after it was found on the floor, risking infection for 1 of 41 sampled residents.
Report Facts
Sampled residents: 41
Residents affected by environment deficiency: 5
Residents affected by abuse reporting deficiency: 4
Residents affected by abuse investigation deficiency: 3
Residents affected by ADL assistance deficiency: 2
Residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator (ADM) | Facility Administrator and Abuse Coordinator | Named in multiple interviews regarding abuse reporting and investigation deficiencies |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Named in interviews regarding incident documentation and reporting |
| Director of Nursing (DON) | Director of Nursing | Named in interviews regarding abuse investigations, shower scheduling, and infection control |
| Housekeeper (HK) 1 | Housekeeper | Named in interview regarding cleaning schedules and staffing |
| Registered Nurse (RN) 1 | Registered Nurse | Named in interview regarding resident 3's behavior and abuse allegations |
| Registered Nurse (RN) 2 | Registered Nurse | Named in interview regarding shower documentation and resident care |
| Registered Nurse (RN) 4 | Registered Nurse | Named in interview regarding resident 3's behavior and abuse allegations |
| Nursing Assistant (NA) 1 | Nursing Assistant | Named in interview regarding shower scheduling and documentation |
| Nursing Assistant (NA) 3 | Nursing Assistant | Named in interview regarding shower scheduling and resident care |
| Certified Nurse Assistant (CNA) 2 | Certified Nurse Assistant | Named in interview regarding shower refusals and oxygen tubing |
| Certified Nurse Assistant (CNA) 3 | Certified Nurse Assistant | Named in interview regarding oxygen tubing infection control |
| Certified Nurse Assistant (CNA) 6 | Certified Nurse Assistant | Named in interview regarding oxygen tubing change procedures |
| Certified Nurse Assistant (CNA) 7 | Certified Nurse Assistant | Named in observation and interview regarding oxygen tubing contamination |
Inspection Report
Immediate Jeopardy
Census: 41
Deficiencies: 20
Date: Feb 14, 2023
Visit Reason
The survey was conducted to investigate multiple compliance and quality of care issues including medication management, resident safety, abuse allegations, infection control, and care planning.
Findings
The facility was found to have immediate jeopardy related to unsafe smoking practices causing resident injury, failure to ensure adequate supervision and assessment for smoking safety, failure to notify physicians of critical lab values, incomplete care plans, missing laboratory and hospital records, failure to provide timely behavioral health services, medication administration errors, and incomplete documentation of abuse investigations.
Deficiencies (20)
F 0554: The facility failed to ensure residents self-administering medications were clinically evaluated for safety and supervised as appropriate, resulting in unsafe self-administration practices for two residents.
F 0580: The facility failed to notify the physician of a resident's critical blood sugar levels as ordered, risking inadequate treatment.
F 0584: The facility failed to maintain a clean, safe, and homelike environment; resident rooms and equipment were dirty and furniture was broken.
F 0600: The facility failed to protect residents from abuse by another resident and failed to thoroughly investigate and document abuse allegations.
F 0609: The facility failed to report immediately to the State Survey Agency and other authorities an incident involving a resident's injury and abuse allegations.
F 0641: The facility failed to accurately reflect PASRR Level II status on Minimum Data Set assessments for five residents.
F 0644: The facility failed to coordinate PASRR Level II evaluations for a resident requiring specialized mental health services.
F 0655: The facility failed to develop baseline care plans within 48 hours of admission that included hospice or palliative care instructions for three residents.
F 0656: The facility failed to provide timely and consistent assistance with activities of daily living including bathing for two residents.
F 0684: The facility failed to provide hospice communication notes in resident records and staff reported poor communication with hospice providers.
F 0689: The facility failed to ensure safe smoking practices including assessment, supervision, and environmental safety, resulting in a resident sustaining second degree burns and multiple residents smoking unsupervised.
F 0732: The facility failed to post daily nurse staffing information in a prominent and accessible location for residents and visitors.
F 0740: The facility failed to provide necessary behavioral health care and services to a resident with suicidal ideation and multiple psychiatric diagnoses.
F 0757: The facility failed to ensure residents' drug regimens were free from unnecessary drugs, including failure to hold medications per physician parameters and lack of monitoring for adverse effects.
F 0775: The facility failed to maintain complete laboratory reports in resident records, including missing sensitivity reports and hospital documentation.
F 0791: The facility failed to provide or obtain routine dental services and did not document dental visits or refusals for a resident with ill-fitting dentures.
F 0839: The facility failed to ensure all professional staff were licensed, certified, or registered in accordance with state laws; a nurse with a surrendered license was providing care.
F 0842: The facility failed to maintain complete, accurate, and accessible medical records including inaccurate documentation of blood pressure sites and missing hospital records.
F 0855: The facility failed to provide timely behavioral health services and referrals for a resident with documented mental health needs and suicidal ideation.
F 0880: The facility failed to maintain an infection prevention and control program; oxygen tubing was found on the floor and offered to a resident, risking infection.
Report Facts
Residents sampled: 41
Residents affected: 2
Residents affected: 9
Residents affected: 5
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 9
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patient Care Coordinator | Nurse | Provided wound care despite license suspension; involved in resident injury incident |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication monitoring, lab result follow-up, and hospice communication |
| Licensed Practical Nurse 4 | LPN | Interviewed regarding medication administration and lab result monitoring |
| Registered Nurse 1 | RN | Interviewed regarding blood sugar monitoring and notification |
| Resident Advocate | Resident Advocate | Interviewed regarding behavioral health referrals and nurse staffing information |
Inspection Report
Routine
Deficiencies: 21
Date: Jul 15, 2021
Visit Reason
Routine state inspection survey of Mt. Olympus Rehabilitation Center to assess compliance with healthcare regulations including resident rights, safety, care, and infection control.
Findings
The facility was found deficient in multiple areas including resident rights, care planning, medication management, infection control, food quality, behavioral health services, and environmental conditions. Several residents were not provided appropriate care or protections, including inadequate supervision, incomplete care plans, medication errors, and infection prevention lapses.
Deficiencies (21)
F 0550: Facility did not ensure residents exercised their rights to dignified existence and self-determination; residents were not allowed to go to the store due to COVID-19 restrictions without clear guidance or accommodations.
F 0582: Facility failed to provide residents notice of Medicaid/Medicare coverage and potential liability; residents were not issued or did not sign Notice of Medicare Non-coverage forms as required.
F 0584: Facility did not provide a safe, clean, comfortable and homelike environment; sticky floors, stains, missing baseboards, soiled fans, unclean wheelchairs, debris, and odors were observed in multiple resident rooms and common areas.
F 0600: Facility failed to protect residents from abuse and neglect; resident-to-resident altercations occurred without adequate behavioral health interventions or care planning, and investigations were incomplete.
F 0610: Facility failed to respond appropriately to all alleged abuse violations; physical abuse incidents were not thoroughly investigated or prevented, and residents were not adequately protected.
F 0622: Facility did not ensure safe and effective transfer of resident to hospital; transfer paperwork including contact information, advance directives, and discharge summary were missing for resident transferred to hospital.
F 0655: Facility failed to develop and implement baseline care plans for residents; resident 228 lacked care plan for eating assistance and therapy needs, and other residents lacked care plans for urinary tract infection, falls, behavioral health, and CPAP use.
F 0656: Facility did not develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for multiple residents; care plans were missing or incomplete for smoking safety, resident altercations, urinary tract infection, falls, behavioral health, and CPAP use.
F 0684: Facility failed to provide treatment and care according to orders and resident preferences; resident 43 repeatedly consumed alcohol without intervention and required hospitalization, and resident 40 had delayed treatment for urosepsis requiring hospitalization.
F 0689: Facility failed to ensure safe environment and adequate supervision; resident 52 smoked unsupervised despite impaired cognition and shaking hands, and resident 78 repeatedly eloped intoxicated without adequate supervision or intervention.
F 0690: Facility failed to provide appropriate care to prevent urinary tract infections; resident 39 was observed saturated with urine for over 4 hours without incontinence care.
F 0695: Facility did not provide safe and appropriate respiratory care; resident 60 required a CPAP machine that was not provided or properly maintained, and cleaning of CPAP machines was inconsistent.
F 0740: Facility failed to safeguard resident-identifiable information and maintain complete medical records; hospice notes, wound documentation, mental health visit notes, and shower sheets were missing or incomplete for multiple residents.
F 0757: Facility did not ensure residents' drug regimens were free from unnecessary drugs; duplicate therapy, medication administration outside parameters, and lack of monitoring were identified for residents 5, 40, and 182.
F 0761: Facility did not label and store drugs and biologicals properly; expired medications and multi-use vials without open dates were found, and medication refrigerator thermometer was frozen and unreadable.
F 0804: Facility failed to provide food and drink that was palatable, attractive, and at safe temperatures; residents complained of poor food quality, bland taste, cold meals, and resident council minutes documented food complaints.
F 0812: Facility did not store, prepare, distribute, and serve food in accordance with professional standards; outdated and unlabeled food was found in refrigerators, kitchen areas were soiled, and food was transported uncovered through hallways.
F 0842: Facility did not maintain complete, accurate, and accessible medical records; hospice notes were missing, shower sheets were not scanned, and behavioral health documentation was incomplete.
F 0849: Facility did not arrange for hospice services with a written agreement signed by authorized representatives; communication and documentation with hospice providers were inconsistent and incomplete.
F 0880: Facility failed to implement an infection prevention and control program; staff did not consistently wear required PPE, reusable gowns were worn without changing between residents, meal trays from isolation rooms were not handled separately, and cleaning practices were inadequate.
F 0923: Facility did not have adequate outside ventilation by window or mechanical means; strong urine and bowel movement odors were detected throughout the facility, exacerbated by a broken carpet cleaning machine.
Report Facts
Deficiencies cited: 21
Medication doses administered: 21
Medication doses administered: 20
Medication doses administered out of parameters: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Interviewed regarding medication storage and infection control practices |
| RN 1 | Registered Nurse | Interviewed regarding medication administration and infection control |
| DON | Director of Nursing | Interviewed regarding multiple findings including medication errors, infection control, hospice communication, and care planning |
| LCSW | Licensed Clinical Social Worker | Interviewed regarding behavioral health services and resident abuse investigations |
| PCC | Personal Care Coordinator | Interviewed regarding hospice communication and shower sheets |
| DM | Dietary Manager | Interviewed regarding food quality and kitchen sanitation |
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