Mt. Olympus Rehab: Immediate Jeopardy Safety - UT
The fatal incident occurred at Mt. Olympus Rehabilitation Center during an evening admission when two nursing assistants used a transfer sling that came with the resident from another facility. Federal inspectors found the death represented immediate jeopardy to resident safety.
CNA 2, who was responsible for the section where the resident was being placed, said they knew from the report that the resident would require the Hoyer lift due to her size. When the resident arrived on a gurney with a sling underneath her, CNA 2 decided to use it because "it was familiar to them and they did not usually get admissions in the evening."
The sling was made from plastic-like, tarp-like material with multiple straps on the sides and two straps on each corner. CNA 2 told investigators she was familiar with the sling and knew it was a Hoyer sling, though she noted it was not the mesh type she typically used.
CNA 1 brought in the Hoyer lift that also weighed residents. The two assistants put the resident on the lift using four straps on each side and obtained a weight of 325 pounds.
The equipment failed at the worst possible moment.
CNA 2 bent down to move the bed control and the resident's oxygen tubing when the sling straps snapped. The resident fell on top of the Hoyer lift, with CNA 2 falling over the two metal legs of the equipment. One leg ended up behind the resident's neck, the other on her coccyx area.
A nurse came into 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. However, emergency responders discovered the resident was designated do-not-resuscitate and stopped CPR. She was pronounced dead.
Police officers arrived at the facility and turned the room into a crime scene. They questioned both nursing assistants about how they had connected the straps on the Hoyer lift.
The inspection revealed significant gaps in staff training on transfer equipment. CNA 5, employed at the facility for nine years, told investigators she had not received any hands-on training regarding the use of Hoyer lifts and slings. She said Hoyer slings were kept downstairs in the laundry room.
CNA 6, who had worked at the facility for 40 years, said she had training on the Hoyer lift but it had been "a couple years." She was unsure if there had been more recent training that she had missed.
The facility currently had about five residents who used Hoyer lifts, according to staff interviews.
Training practices appeared inconsistent across the facility. CNA 7 said he had received training on Hoyer lift policies just a couple days before the inspection. CNA 8 reported hands-on training about a month earlier and said when the facility received new Hoyer slings, staff had to "visualize the new slings and sign off that they saw them."
CNA 1 described the fatal transfer sling as having tabs at the shoulders and mid-thigh areas used to help lift patients. She said the straps appeared intact without visible wear or tear, but noted the sling was "not a Hoyer lift sling, it was a transfer sling."
Despite this distinction, CNA 1 said she had used similar transfer slings with Hoyer lifts in the past without issues. She noted the facility had obtained these types of slings from other facility transfers.
The incident highlighted the risks of using unfamiliar equipment during patient transfers, particularly for residents requiring mechanical assistance due to their size or mobility limitations. The resident's death occurred during what should have been a routine admission process, turning a standard transfer into a fatal equipment failure.
Federal inspectors classified the violation as immediate jeopardy, the most serious level of harm in nursing home regulations.
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 fatal incident occurred at Mt.
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.