Inspection Reports for
Thatcher Brook Rehabilitation & Care Center
1795 South Chelemes Way, Clearfield, UT, 84015
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
24% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 6
Date: Jul 23, 2025
Visit Reason
Unannounced routine inspection to assess compliance with Utah nursing care facility regulations.
Findings
The inspection reviewed compliance with multiple regulatory requirements including resident rights, care planning, medication management, staffing, emergency preparedness, and facility maintenance. Several minor noncompliances were noted and technical assistance was provided.
Deficiencies (6)
R432-150-11(4)(a-x) The licensee failed to ensure each resident admitted has all resident rights including privacy, visitation, confidentiality, and freedom from abuse. One citation was issued.
150-17(4) Pharmacy personnel did not ensure medication labels included all required information and expiration dates.
150-17(5)(a-d) The licensee failed to store drugs and biologicals in locked compartments with proper temperature controls and prevent unauthorized access.
150-18(1) The licensee did not provide an ongoing program of individual and group activities to meet residents' physical, mental, and psychosocial well-being.
150-20(6)(a-c) The licensee failed to provide written notification of resident transfer or discharge in a timely manner with required information.
R432-35-3(3) The covered provider did not ensure DACS reflected the current status of covered individuals within five working days of engagement or termination.
Report Facts
Number of rule noncompliances: 10
Citation count: 1
Inspection Report
Annual Inspection
Deficiencies: 6
Date: 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 deficiencies were identified related to emergency preparedness, life safety code violations including means of egress obstructions, fire door inspections, hazardous area separations, and electrical system maintenance.
Deficiencies (6)
42 CFR 483.73(a): The facility failed to develop and maintain a comprehensive emergency preparedness program that is reviewed and updated at least annually.
NFPA 101 19.2.1, 7.1.10.1: The facility did not continuously maintain means of egress and exits to the public way free of obstructions at all times.
NFPA 101 19.3.2.1, 19.3.5.9: The facility failed to maintain hazardous areas separated by fire and smoke barriers as required, affecting 1 of 5 smoke compartments.
NFPA 101 19.3.7.8: The facility did not maintain fire doors in smoke barriers to have at least a 20-minute fire protective rating and self-closing or automatic closing features, affecting 2 of 5 smoke compartments.
NFPA 110, NFPA 99: The facility failed to maintain, inspect, and exercise the emergency generator's remote manual stop as required, affecting 1 remote manual stop.
NFPA 101, NFPA 70: The facility used flexible extension cords improperly in patient care areas and failed to remove them, affecting 1 of 5 smoke compartments.
Report Facts
Deficiencies cited: 6
Smoke compartments affected: 5
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