Inspection Reports for Thatcher Brook Rehabilitation & Care Center
1795 South Chelemes Way, UT, 84015
Back to Facility ProfileDeficiencies per Year
24
18
12
6
0
Moderate
Unclassified
Inspection Report
Routine
Deficiencies: 21
Jul 23, 2025
Visit Reason
The inspection was an unannounced routine inspection conducted to review compliance with state nursing care facility regulations.
Findings
The inspection checklist shows multiple areas of compliance and noncompliance across various regulatory requirements including resident rights, medication management, staffing, emergency preparedness, and facility maintenance. Several rules were found compliant while others had noncompliance noted, with technical assistance provided in some areas.
Deficiencies (21)
| Description |
|---|
| Identification badges for employees providing direct care were not compliant. |
| Providers' duty to help protect clients was not fully compliant. |
| Policy, procedures, and employee training requirements were not fully met. |
| Scope of services for intermediate and skilled nursing care facility levels were partially noncompliant. |
| Respite care policies and procedures were not fully compliant. |
| Adult day care services policies and procedures were partially noncompliant. |
| Governing body responsibilities and administrator qualifications were partially noncompliant. |
| Medical director and physician services requirements were partially noncompliant. |
| Staff and personnel policies including health screening, immunizations, and training were partially noncompliant. |
| Quality assurance plan and resident rights postings were partially noncompliant. |
| Resident rights including privacy, visitation, and grievance procedures were partially noncompliant. |
| Restraint policies and use were partially noncompliant. |
| Quality of care including nutrition, feeding assistance, and medication management were partially noncompliant. |
| Pharmacy services including drug storage, emergency drug supply, and medication error monitoring were partially noncompliant. |
| Recreation therapy services and management of resident funds were partially noncompliant. |
| Housekeeping, laundry, and maintenance services were partially noncompliant. |
| Emergency response and preparedness plans were partially noncompliant. |
| Alternative sanctions for nursing facilities and annual reporting requirements were partially noncompliant. |
| Vaccination offer and exemptions policies were partially noncompliant. |
| Covered provider background check and certification processes were partially noncompliant. |
| Orders for Life-Sustaining Treatment (OLST) policies, training, and compliance were partially noncompliant. |
Report Facts
Number of rule noncompliances: 10
Inspection Report
Annual Inspection
Deficiencies: 7
Sep 27, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 09/25/2023 to 09/27/2023 to assess compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance overall but had deficiencies related to emergency preparedness and life safety code requirements including failure to maintain a comprehensive emergency preparedness program, means of egress obstructions, fire door maintenance, hazardous area separations, and electrical system issues.
Severity Breakdown
D: 2
E: 5
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to develop and maintain a comprehensive emergency preparedness program that is reviewed and updated at least annually. | D |
| Facility did not continuously maintain means of egress and exits to the public way free of obstructions. | E |
| Facility failed to provide documentation of annual fire door assembly inspection and maintain fire doors to latch properly. | E |
| Facility did not maintain hazardous areas to be fire and smoke separated in accordance with NFPA 101. | E |
| Facility did not maintain door openings in smoke barriers to have at least a 20 minute fire protective rating and self-closing or automatic closing doors. | E |
| Facility did not maintain, inspect, and exercise the emergency generator set in accordance with NFPA standards; lacked remote manual stop. | E |
| Facility did not use power and extension cords in accordance with NFPA standards; flexible extension cords were improperly used. | D |
Report Facts
Deficiency affected smoke compartments: 1
Deficiency affected smoke compartments: 2
Deficiency affected inspections: 1
Deficiency affected remote manual stops: 1
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