Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mt. Olympus Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions was fatally injured after being transferred with a Hoyer lift using a transfer sheet instead of an approved Hoyer sling. Two CNAs used the sheet that arrived with the resident, despite warnings from the transport driver and without verifying its compatibility. The straps broke during the transfer, causing the resident to fall. Staff interviews revealed a lack of proper training and inconsistent enforcement of equipment policies.
Nursing staff lacked proper training and competency in the use of Hoyer lifts and slings, leading to a fatal incident where a resident was transferred using a transfer sheet instead of an approved lift sling. The transfer sheet's straps broke during the lift, causing the resident to fall and subsequently die. Staff interviews revealed confusion about equipment use and inadequate training, with some CNAs admitting to using transfer sheets with lifts and not being updated on current policies.
A facility failed to notify the Ombudsman when a resident with complex medical conditions was transferred to the hospital for Acute Hypoxic Respiratory Failure. The Resident Advocate was unaware of the requirement to inform the Ombudsman of such transfers.
Four residents with cognitive impairments eloped from a facility due to inadequate supervision and improper use of wanderguards without physician orders. Despite being identified as high-risk for wandering, the facility failed to implement additional interventions after residents repeatedly removed their wanderguards, leading to multiple elopements.
A registered nurse failed to follow infection control protocols during a medication pass by not performing hand hygiene and handling medications with bare hands. The Director of Nursing confirmed that these actions were against facility expectations, highlighting a need for further education on proper medication administration procedures.
The facility did not develop baseline care plans within 48 hours for two residents, leading to a deficiency. One resident with Parkinson's and dementia, and another with osteoarthritis and diabetes, both lacked timely care plans due to incomplete admission assessments. The DON noted that the nursing administration was responsible for ensuring these plans were completed.
The facility failed to develop and revise care plans for two residents within the required timeframe, leading to repeated elopement incidents. One resident with traumatic brain injury and dementia exhibited wandering behaviors that were not addressed promptly, while another resident with severe cognitive impairment had an outdated care plan despite multiple elopement attempts. The facility lacked documentation of effective interventions and physician orders for wanderguards, as confirmed by staff interviews.
A resident with multiple diagnoses, including hypertension, received blood pressure medications outside of the physician's ordered parameters. Despite protocols to hold medication if systolic blood pressure was below 110, records showed administration when levels were lower. Staff interviews confirmed the expectation to follow these parameters, highlighting a failure in adherence.
The facility did not properly label and handle narcotics, as observed in the Quail hallway medication cart where Tramadol 50 mg was improperly taped back into a medication card. An RN and the DON confirmed that narcotics should be wasted by two nurses and documented, not re-taped, to prevent infection and incorrect medication placement.
Resident Death Following Use of Inappropriate Transfer Device with Hoyer Lift
Penalty
Summary
A deficiency occurred when a resident was transferred using a Hoyer lift with a transfer sheet rather than an approved Hoyer sling, resulting in the resident being dropped and subsequently dying. The resident, who had recently been admitted with diagnoses including acute gastric ulcer with hemorrhage, unspecified diastolic heart failure, and morbid obesity, arrived at the facility on a stretcher with a transfer sheet underneath her. Two CNAs decided to use the transfer sheet already under the resident for the Hoyer lift transfer, despite it not being an approved or compatible sling for the lift. During the transfer, the straps of the transfer sheet snapped, causing the resident to fall onto the legs of the Hoyer lift. Immediate attempts at resuscitation were made, but the resident was pronounced deceased after EMS arrived and identified a DNR order. Interviews with staff revealed that the CNAs were familiar with using transfer sheets in place of Hoyer slings and had done so previously without incident. The CNAs did not verify whether the sling was approved for use with the Hoyer lift, and one CNA stated that she had used similar transfer slings in the past. The LPN on duty was not present in the room during the transfer but responded after hearing a yell and a thud, finding the resident on the floor. The transport driver who brought the resident to the facility expressed concern about using the transfer sheet for the Hoyer lift and advised against it, but the CNAs proceeded regardless. Further investigation found that staff training on the proper use of Hoyer lifts and slings was lacking, with some CNAs reporting they had not received hands-on training since their initial orientation. Facility policy regarding the exclusive use of facility-owned and approved slings was not consistently communicated or enforced among staff. Observations also indicated that Hoyer slings and transfer equipment were stored in a manner that could lead to confusion about which items were appropriate for use with the mechanical lift.
Failure to Ensure Competent Use of Mechanical Lifts and Slings Resulting in Resident Death
Penalty
Summary
Nursing staff at the facility did not possess the necessary competencies and skills to safely use mechanical lifts and slings for resident transfers, as evidenced by direct observations, interviews, and record reviews. Certified Nursing Assistants (CNAs) were not adequately educated on the correct use of Hoyer lifts, the identification and use of approved Hoyer slings, or how to distinguish transfer sheets from lift slings. Multiple staff members reported either never receiving hands-on training or only having received training many years prior, with some staff indicating they had not been updated on new policies or equipment. A critical incident occurred when a newly admitted resident, who had significant medical conditions including acute gastric ulcer with hemorrhage, congestive heart failure, and morbid obesity, was transferred from another facility. The resident arrived on a stretcher with a blue transfer sheet underneath her. CNAs at the receiving facility used the transfer sheet, mistaking it for a Hoyer lift sling, to transfer the resident using a mechanical lift. Despite warnings from the transport driver that the sheet was not intended for use with a lift, the CNAs proceeded. During the transfer, the straps of the transfer sheet broke, causing the resident to fall onto the legs of the Hoyer lift. The resident became unresponsive and was later pronounced deceased. Interviews with staff revealed a lack of understanding regarding the differences between transfer sheets and Hoyer slings, as well as inconsistent practices regarding the use of slings that accompanied residents from other facilities. Some CNAs admitted to routinely using transfer sheets with Hoyer lifts, while others were unclear about the proper procedures or the lifespan of slings. The facility's policy regarding the exclusive use of facility-owned and approved equipment had not been communicated to all staff at the time of the incident.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman regarding the transfer or discharge of a resident to the hospital. This deficiency was identified for one of the 38 sampled residents, specifically when a resident was discharged to the hospital due to a change in condition. The resident, who had a complex medical history including peripheral vascular disease, chronic obstructive pulmonary failure, type 2 diabetes mellitus with diabetic neuropathy, and other conditions, was admitted to the hospital for Acute Hypoxic Respiratory Failure. During an interview, the Resident Advocate admitted to not notifying the Ombudsman of the transfer, stating a lack of awareness of the requirement to do so.
Inadequate Supervision and Assistance Devices Lead to Multiple Elopements
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for four residents, leading to multiple elopements. Resident 120, with a history of traumatic brain injury and moderate cognitive impairment, was placed with a wanderguard without a physician's order or assessment. Despite being identified as a high risk for wandering, the resident eloped twice, once by removing the wanderguard and another time when left unsupervised momentarily by a CNA. The facility did not implement additional interventions after the resident repeatedly removed the wanderguard. Resident 121, diagnosed with traumatic brain injury and vascular dementia, also experienced multiple elopements. The resident's care plan for wandering was developed only after several incidents, despite being identified as having moderate cognitive impairment and wandering behaviors. The facility failed to document other interventions to prevent elopement after the resident removed the wanderguard multiple times, and no physician's order for the wanderguard was found in the medical record. Residents 125 and 127 also faced similar issues with inadequate supervision and lack of proper assessments for wanderguards. Resident 125, with schizoaffective disorder and moderate cognitive impairment, eloped and was later found by local transport. The resident's wanderguard was placed without a physician's order, and no additional interventions were documented. Resident 127, with severe cognitive impairment and a history of wandering, eloped despite having a wanderguard, which was not ordered by a physician. The facility did not update the care plan or implement other interventions to prevent further elopements.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a registered nurse (RN) during a medication pass. On the morning of May 8, 2024, RN 2 was observed not performing hand hygiene before starting the medication pass. During the process, RN 2 used her bare fingers to retrieve a medication from a cup, inadvertently touching the medication and the sides of the cup. Despite this, she continued the medication pass without restarting the process for the affected resident. Additionally, RN 2 was seen handling a tablet with her bare fingers, placing it on a pill cutter, and then transferring the cut tablet into a medication cup, which was subsequently administered to a resident. These actions were contrary to the facility's expectations, as confirmed by the Director of Nursing (DON), who stated that hand hygiene should be performed, and medications should not be touched with bare hands. The DON acknowledged that medication pass education was necessary, indicating a gap in adherence to infection control protocols.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, resulting in a deficiency. Resident 55, who was initially admitted and later readmitted with multiple diagnoses including Parkinson's disease, dementia, and neuromuscular dysfunction of the bladder, did not have a baseline care plan developed until seven days after admission. Similarly, Resident 167, admitted with conditions such as right hip osteoarthritis, chronic lymphocytic leukemia, and type II diabetes, also lacked a baseline care plan until seven days post-admission. The Director of Nursing (DON) explained that the baseline care plan should be generated from an admission assessment conducted by the admitting nurse. However, for both residents, this assessment was not completed, preventing the creation of the necessary care plans. The DON acknowledged that the nursing administration was responsible for ensuring the completion of these baseline care plans, but the oversight led to the deficiency noted by the surveyors.
Deficient Care Plan Development and Revision for Residents
Penalty
Summary
The facility failed to ensure that care plans for two residents were developed within 7 days after the completion of their comprehensive assessments and were not revised by the interdisciplinary team after each assessment. Resident 121, who was admitted with diagnoses including traumatic brain injury and vascular dementia, exhibited wandering and elopement behaviors that were not addressed in a timely manner. Despite multiple incidents of elopement and exit-seeking behavior, a care plan addressing these issues was not developed until several weeks after the initial assessment. The resident's medical record lacked documentation of effective interventions to prevent further elopement, and there was no physician's order for the use of a wanderguard, which the resident frequently removed. Resident 127, admitted with severe cognitive impairment and a history of wandering, also had an outdated care plan that was not revised despite multiple elopement attempts. The resident's wander risk assessment indicated a high risk of wandering, yet the care plan had not been updated since its initial development. The resident's progress notes documented several instances of exit-seeking behavior, but there was no evidence of additional interventions beyond the use of a wanderguard, which also lacked a physician's order. Interviews with facility staff, including the Director of Nursing, confirmed the deficiencies in care plan development and revision for both residents. The facility's failure to timely update and implement effective care plans for residents 121 and 127 contributed to repeated elopement incidents, highlighting a significant lapse in addressing the residents' safety and care needs.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, as evidenced by the administration of blood pressure medications outside of the physician's ordered parameters. Resident 4, who had multiple diagnoses including hypertension, was prescribed Chlorthalidone and Amlodipine with specific instructions to hold the medication if the systolic blood pressure was less than 110. However, the medication administration records for March, April, and May 2024 showed that these medications were administered on several occasions when the resident's blood pressure was below the specified threshold. Interviews with the facility's staff, including a Registered Nurse and the Director of Nursing, confirmed that there were established blood pressure parameters that were expected to be followed to ensure resident safety. The staff acknowledged that the nurses were supposed to check the blood pressure before administering the medication and hold it if the blood pressure was below the ordered parameters. Despite these protocols, the medications were administered inappropriately, indicating a failure to adhere to the physician's orders and the facility's procedures for medication administration.
Improper Labeling and Handling of Narcotics
Penalty
Summary
The facility failed to label all drugs and biologicals in accordance with currently accepted professional principles, specifically concerning the handling of narcotics. During an observation of the medication cart in the Quail hallway, it was found that a medication card containing Tramadol 50 mg had pockets numbered 10 and 20 taped, with a white tablet in each pocket. An interview with an RN revealed that narcotics are supposed to be wasted by two nurses and documented in the narcotic book, not taped back into the medication card. The Director of Nursing confirmed that the expected procedure is for nurses to waste narcotics with another nurse and sign off in the narcotic book, emphasizing that re-taping medication into cards is not allowed as it could lead to infection and incorrect medication placement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Salt Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monument Healthcare Canyon Rim | 1 mi | ★★★★★ | 0 | 0 |
| Millcreek Rehabilitation And Nursing | 1.3 mi | ★★★★★ | 3 | 0 |
| Highland Care Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Spring Creek Healthcare Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Monument Healthcare Murray Creek | 2.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.