Mt. Olympus Rehab: Immediate Jeopardy Citation - UT
The resident arrived at the facility on a gurney with a transfer sling underneath her body. Two nursing assistants decided to use that sling rather than getting a facility sling, even though they knew the resident would require the Hoyer lift due to her size.
CNA 2, who was responsible for the resident's section, said the sling was made from plastic-like material that was "tarp-like" with multiple straps on the sides and two straps on each corner. She told inspectors she was familiar with this type of sling and had only used the blue tarp-like ones, never the mesh versions.
The nursing assistants attached the resident to the Hoyer lift using four straps on each side and obtained a weight of 325 pounds. CNA 2 bent down to move the bed control and the resident's oxygen tubing when the sling straps suddenly snapped.
The resident fell on top of the Hoyer lift. One metal leg ended up behind her neck, the other on her coccyx area.
A nurse entered the room and helped pull the resident off the Hoyer lift legs to lay her flat on the floor. They began CPR immediately. EMS arrived and took over resuscitation efforts, but discovered the resident had a do-not-resuscitate order. CPR was stopped and the resident was pronounced dead.
Police officers arrived at the facility and turned the room into a crime scene, questioning the two nursing assistants about how they had attached the straps to the Hoyer lift.
CNA 1, who brought in the Hoyer lift that also weighed residents, told inspectors the transfer sling that came with the resident was not a standard Hoyer lift sling. She said the straps appeared intact without wear or tear, and she had used similar transfer slings with Hoyer lifts in the past without issues. The facility had obtained these types of slings from other facility transfers.
CNA 2 explained they used the resident's sling because it was familiar to them and they did not usually get admissions in the evening. She said they examined the straps and decided to use multiple straps as an option.
The facility's training records revealed significant gaps in staff preparation for Hoyer lift operations.
CNA 5, employed at the facility for nine years, stated she had not received any hands-on training regarding the use of Hoyer lifts and slings. She knew Hoyer slings were kept downstairs in the laundry room and that about five residents currently used the lifts.
CNA 6, who had worked at the facility for 40 years, said her last Hoyer lift training was a couple of years ago. She thought there might have been another training session since then that she had missed but was unsure.
CNA 7 received training on Hoyer lift policies just days before the incident. CNA 8's last hands-on training was about a month prior to the death.
When the facility acquired new Hoyer slings, staff were only required to visualize the new equipment and sign off that they had seen them, according to CNA 8.
The incident occurred during an evening admission when normal procedures may have been rushed. The resident arrived needing immediate transfer assistance due to her weight and mobility limitations.
Federal inspectors classified the violation as immediate jeopardy to resident health or safety, affecting few residents. The investigation revealed both equipment safety failures and training deficiencies that contributed to the fatal outcome.
The resident's death transformed what should have been a routine transfer into a police investigation, highlighting the life-or-death consequences of improper equipment use in nursing facilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mt. Olympus Rehabilitation Center from 2025-10-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Mt. Olympus Rehabilitation Center in Salt Lake City, UT was cited for immediate jeopardy violations during a health inspection on October 24, 2025.
The resident arrived at the facility on a gurney with a transfer sling underneath her body.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.