Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Thatcher Brook Rehabilitation & Care Center during CMS and state inspections, most recent first.
Surveyors found that drugs and biologicals were not consistently labeled with open or expiration dates, including insulin vials and pens for two residents with diabetes. Medications such as sucralfate and daptomycin were improperly stored in a medication room sink, and a medication cart was observed left unlocked and unattended. Staff interviews confirmed these practices did not align with facility policy or professional standards.
Several residents reported dissatisfaction with meal quality, including unappetizing taste, tough meat, lack of seasoning, and cold or improperly prepared food. Observations of a test tray confirmed issues with food temperature and appearance. Dietary staff relied on informal feedback, and alternative menu options were not consistently offered or accessible.
Surveyors found that food items in the kitchen were not consistently stored, labeled, or sealed according to professional standards, with multiple items left open to air in freezers and refrigerators, and some lacking required dates. The stove and oven surfaces were also observed to be unclean, with crumbs, debris, grease, and powder present. Staff interviews confirmed that procedures for dating and sealing food were in place but not consistently followed.
Staff failed to consistently follow Enhanced Barrier Precautions and infection control protocols, including not donning required PPE, not performing hand hygiene during dressing changes, and improper cleaning techniques for central line care. PPE signage was inconsistently marked, and staff demonstrated confusion about EBP requirements, resulting in care for residents with wounds, central lines, and indwelling devices being provided without appropriate infection prevention measures.
A resident with limited mobility and dexterity, requiring assistance with eating, was observed being fed by a CNA who stood at the bedside rather than sitting, contrary to facility expectations. The DON confirmed that staff should be seated while feeding residents to maintain dignity and respect.
A resident with complex medical needs was emergently transferred to the hospital after a seizure, but the facility did not provide written notice of transfer or discharge, nor written information about the bed-hold policy, to the resident or their representative as required. Verbal notification was given, but no written documentation was included with the transfer or provided afterward.
Two residents with documented preferences for group and individual activities were only offered bingo three times a week, with no other scheduled activities provided. Interviews and review of the activities calendar confirmed the lack of variety, and both the Activities Director and Administrator acknowledged that other available materials and options were not actively promoted or scheduled.
A resident with severe cognitive impairment and a history of falls did not have new interventions added to their care plan after experiencing multiple falls. Despite repeated incidents and the resident's ongoing fall risk, staff relied on verbal communication and did not formally update the care plan with new measures following each event.
A resident with end stage renal disease, sepsis, and heart failure did not receive immediate monitoring or documentation of vital signs and dialysis fistula assessment upon return from dialysis. Staff relied on information from the dialysis center and performed assessments at other times, but did not follow facility expectations for immediate post-dialysis evaluation and documentation.
A resident with a prescribed soft-bite and pre-cut food diet did not receive appropriate menu substitutions for garlic bread and salad, as required by her dietary restrictions. Despite the menu indicating alternatives should be provided, the resident was served a meal without suitable substitutes, leading to dissatisfaction and a failure to meet her nutritional needs.
A resident with multiple chronic conditions and a documented dislike of pork and pork products was repeatedly served sausage, despite her preferences being clearly noted on her dietary records and meal tickets. Staff interviews and record reviews confirmed that the resident's dislikes were known, but pork products were still provided.
A resident with a history of recurrent UTIs was prescribed Macrobid daily as a prophylactic antibiotic without documented evidence of current infection or symptoms, and the order lacked a stop date. The facility's antibiotic stewardship policy required clear documentation of treatment duration and monitoring, but these protocols were not followed, resulting in a deficiency related to antibiotic use monitoring.
A resident with multiple chronic conditions received the initial PCV-13 pneumococcal vaccine, but the facility failed to document administration, offer, or declination of the second recommended pneumococcal vaccine dose. The resident's vaccination status was marked as 'unable to determine,' and there was no evidence that the required follow-up was completed according to facility policy.
Deficiencies in Medication Storage, Labeling, and Security
Penalty
Summary
Surveyors identified multiple deficiencies related to the storage and labeling of drugs and biologicals for four residents. For one resident with type 2 diabetes mellitus and end stage renal disease, an opened insulin vial was found without an open or expiration date. The responsible RN confirmed the vial was opened and subsequently labeled it during the observation. Another resident with diabetes had an insulin pen in the medication cart that was also missing an open or expiration date, and the LPN interviewed was unsure of the exact duration insulin remained viable after opening. This resident had already been discharged at the time of the observation. Additional deficiencies were observed with medications not being properly stored. A bubble pack of sucralfate for a resident with gastro-esophageal reflux and cyclical vomiting was found in the medication room sink with one tablet remaining. Similarly, compounded daptomycin vials for a resident with sepsis and pneumonia were also found in the medication room sink. The DON stated that medications should not be stored in the sink and explained that these were intended to be returned to the pharmacy, which collects unused medications twice daily. Surveyors also observed a medication cart left unlocked and unattended in a hallway. The DON and LPN confirmed that the cart should be locked when not attended, and the RN responsible for the cart stated she had left her keys with the LPN during her break but was unsure if the cart had been left unlocked. The DON reiterated that medication carts should always be locked when unattended and that no medications or resident information should be left exposed.
Failure to Provide Palatable, Attractive, and Properly Tempered Meals
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for 8 of 26 sampled residents. Multiple residents reported dissatisfaction with the quality, taste, and temperature of the meals served. Specific complaints included food being unappetizing, tough meat, lack of seasoning, cold vegetables, and not receiving menu-listed items or appropriate condiments. Some residents stated they were not offered alternatives and, in some cases, resorted to ordering food from outside sources due to dissatisfaction with facility meals. Observations of meal service and a test tray revealed further issues. The test tray included pork roast that was dry, tough, and served at 124.9°F, wild rice pilaf that was lukewarm and unsavory, overcooked and bland asparagus at 117.3°F, a flattened and unappetizing apple crisp dessert at 53.1°F, and a dinner roll at 70.3°F. These findings confirmed that food was not consistently served at appetizing temperatures or in an appealing manner. Additionally, the test tray and resident interviews indicated that food preparation methods did not conserve flavor or appearance. Interviews with dietary staff revealed that while the Registered Dietitian (RD) and Dietary Manager (DM) were involved in resident assessments and occasional tray audits, feedback mechanisms were informal and not consistently documented. The alternative menu was not readily accessible to all residents, as it was separate from the main menu and only provided upon request. These actions and inactions contributed to the deficiency in providing meals that met regulatory standards for palatability, appearance, and temperature.
Improper Food Storage and Kitchen Cleanliness
Penalty
Summary
Surveyors observed multiple instances where food items in the facility's kitchen were not stored, prepared, or maintained according to professional food service safety standards. During walk-throughs, several food items in both the walk-in and reach-in freezers, such as diced carrots, peas, French toast, cookie dough, sausage links, and dinner rolls, were found open to the air. Additionally, the stove and the top of the oven were noted to have crumbs, debris, grease, and a white powder, indicating a lack of cleanliness. In the walk-in refrigerator, containers of chicken breasts and pork roast were covered with plastic wrap but were not dated, and a large bucket of pickles did not have an open date. Interviews with kitchen staff and the Dietary Manager revealed that food items were supposed to be dated when received and when opened, and that cleaning duties were assigned to all kitchen staff. The Dietary Manager confirmed that food in the refrigerator should be dated even if it was to be used the same day, and that food in the freezer should be sealed to prevent freezer burn. Despite these stated procedures, the observed deficiencies indicated that these practices were not consistently followed, resulting in improper food storage and cleanliness issues.
Failure to Implement and Adhere to Enhanced Barrier Precautions and Infection Control Protocols
Penalty
Summary
Surveyors identified that the facility failed to maintain an effective infection prevention and control program for three out of twenty-six sampled residents. Staff were observed not donning required Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP), not performing hand hygiene during dressing changes, and engaging in cross-contamination during a central line dressing change. Specifically, signage for PPE requirements was inconsistently marked, and staff demonstrated confusion regarding when and what type of PPE was necessary for care activities involving residents with indwelling devices or wounds. For one resident with a central line for IV antibiotic administration due to infective endocarditis, staff did not wear a gown during medication administration or dressing changes, despite EBP policy requiring both gown and gloves for such high-contact care. Additionally, hand hygiene was not performed prior to donning sterile gloves, and improper technique was used when cleaning the central line insertion site, with the nurse going back over the insertion site after cleaning outward. The PPE signage outside the resident’s room was not properly marked until after the dressing change, and staff interviews revealed a lack of understanding about EBP requirements. Other residents with wounds, feeding tubes, or indwelling urinary catheters also had EBP signage posted, but staff were observed providing care and assistance, including transfers and therapy, without donning the required PPE. Interviews with staff indicated inconsistent knowledge and application of EBP protocols, and in some cases, there were no physician orders for EBP found in the records. The facility’s policy required gown and gloves for high-contact care activities for residents with wounds or indwelling devices, but these procedures were not consistently followed.
Staff Stood While Feeding Dependent Resident
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) was observed standing while feeding a resident who was lying in bed with the head of the bed elevated and the bed in its highest position. The resident, who had a history of cellulitis, sepsis, and hypertension, required assistance with eating due to difficulty with dexterity and was dependent on a Hoyer lift for mobility. During interviews, staff confirmed that the resident struggled to feed herself and that CNAs were expected to sit while feeding residents, as stated by the Director of Nursing (DON). However, the observed practice did not align with this expectation, resulting in a failure to treat the resident with respect and dignity and to provide care in a manner that promoted the resident's quality of life and recognized her individuality.
Failure to Provide Written Transfer/Discharge and Bed-Hold Policy Notification
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including a left tibia and fibula fracture, respiratory failure with hypoxia, neuralgia, type 2 diabetes, anxiety disorder, epilepsy, and morbid obesity, was emergently transferred to the hospital after experiencing a seizure and becoming unresponsive. Although internal discharge paperwork was completed, there was no discharge documentation found in the resident's medical record. The facility's policy requires that notice of transfer or discharge, including the reason for transfer and bed-hold policy details, be provided to the resident and their representative in writing as soon as practicable, especially in emergency situations. Interviews with the DON and Administrator revealed that while some paperwork, such as a face sheet, resident orders, and a POLST form, was sent with the resident, no written notice of transfer or discharge or bed-hold policy was provided to the resident or their representative. The DON stated that the bed-hold policy was communicated verbally but not in writing, and the Administrator confirmed that a bed-hold agreement was not sent with residents transferred to the hospital. This failure to provide required written notifications and documentation at the time of transfer or discharge constituted the deficiency.
Failure to Provide Comprehensive Activity Program for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the interests and support the physical, mental, and psychosocial well-being of its residents, as required. For two out of 26 sampled residents, it was observed and confirmed through interviews that the only scheduled activity was bingo, which occurred three times a week, with no other group or individual activities offered. The activities calendar reflected this lack of variety, listing only bingo on select days and leaving other days, including weekends, blank. Residents expressed dissatisfaction, stating there were no other activities available and some days had no activities at all. Review of the residents' medical records showed that both had expressed preferences for group activities and participation in their favorite pastimes, as documented in their Minimum Data Set (MDS) assessments and care plans. Despite these documented preferences, the only interventions listed were to acquaint residents with the facility and its routines. The Activities Director (AD) confirmed that activity packets with puzzles and word games were distributed, and that some materials like books and board games were available, but these were not actively promoted or scheduled as part of a structured program. The AD also stated she had no helpers and had not received training. The Administrator acknowledged the lack of variety in activities and that residents were not informed about available options beyond bingo and activity packets.
Failure to Update Fall Interventions After Multiple Resident Falls
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, generalized weakness, and a history of falls did not have new interventions implemented after experiencing multiple falls. The resident, who was at risk for falls due to lack of coordination and recent hospitalization, experienced at least three documented falls within a short period. Despite these incidents, the care plan was not updated with new interventions following the falls on 7/3/25 and 7/12/25. The existing care plan included general fall prevention measures such as therapy, use of gait belts, frequent safety checks, and encouragement to use the call light, but did not address the specific circumstances or patterns of the recent falls. Interviews with nursing staff and administration revealed inconsistent practices regarding the updating of care plans and communication of interventions. The DON and ADON indicated that interventions were not always updated after each fall, and that staff were often informed of required interventions verbally rather than through formal documentation. The care plan was reviewed only every 30 days, and there was no evidence of new interventions being added after the most recent falls, despite the resident's ongoing risk and repeated incidents.
Failure to Provide Immediate Post-Dialysis Assessment and Documentation
Penalty
Summary
A deficiency was identified in the care of a resident with end stage renal disease, sepsis, and heart failure who required dialysis services. Upon review of the resident's medical record and interviews with the resident, nursing staff, and the Director of Nursing (DON), it was found that the facility did not provide immediate monitoring and documentation of the resident's vital signs or assessment of the dialysis fistula upon the resident's return from the dialysis treatment center. The resident reported that after returning from dialysis, a Certified Nursing Assistant (CNA) assisted him to his room, but no vital signs were taken and a nurse did not assess his dialysis fistula at that time. Further interviews revealed that the LPN relied on the Dialysis Progress Note from the dialysis center, which included vital signs, weights, and new orders, and stated that vital signs were taken in the morning before dialysis and again in the evening, with fistula assessments completed every morning. However, there was no documentation in the resident's medical record of immediate post-dialysis vital signs or fistula assessment. The DON confirmed that facility policy expected nurses to assess the resident and the dialysis fistula immediately upon return from dialysis and to document these findings, but this was not done in this case.
Failure to Provide Appropriate Menu Substitutions for Special Diet
Penalty
Summary
A deficiency was identified when a resident with special dietary needs did not receive appropriate menu substitutions in accordance with her prescribed diet. The resident, who had recently discontinued tube feedings and was transitioning back to oral intake, was observed at lunch receiving spaghetti with small pieces of meat and green peas, along with a pudding-type dessert. The menu for that meal listed spaghetti, garlic bread, and a green salad, but the resident did not receive suitable substitutes for the garlic bread or salad, despite her dietary restrictions. The resident expressed disappointment with her meal, noting the lack of appropriate alternatives. Review of the resident's medical record showed she required a soft-bite and pre-cut food diet, as approved by the Registered Dietitian (RD), and had specific restrictions to avoid certain foods due to severe inflammation and gastric irritants. The daily menu spreadsheet indicated that substitutions should have been provided, such as soft steamed vegetables or mashed vegetables for salad, and pureed bread for garlic bread. The Dietary Manager confirmed that changes to diet orders were communicated by the RD and entered into the dietary system, but acknowledged that appropriate substitutions were not made for this resident's meal.
Failure to Accommodate Resident's Documented Food Preferences
Penalty
Summary
A deficiency was identified when a resident with multiple medical diagnoses, including infective endocarditis, atrial fibrillation, chronic kidney disease, cystitis, type 2 diabetes mellitus, bacteremia, hypolipidemia, and hypokalemia, received food items that did not accommodate her documented dietary preferences and dislikes. The resident had a clearly documented dislike of pork and pork products, including ham and sausage, as noted on her Nutrition Screening Intake Form and her meal ticket. Despite these documented preferences, the resident reported receiving pork products, specifically sausage, on multiple occasions, including during a breakfast observation where a sausage patty was present on her tray. Interviews with the resident, a CNA, and a staff member responsible for dietary preferences confirmed that the resident's dislikes were known and documented, and that pork products should not have been served. The staff member acknowledged that the resident's meal ticket listed pork, ham, and sausage as dislikes and that eggs were typically provided as an alternative. The presence of sausage on the resident's tray was verified by both the CNA and the kitchen, indicating a failure to follow the resident's documented dietary preferences.
Failure to Monitor and Document Antibiotic Use per Stewardship Protocols
Penalty
Summary
A deficiency was identified when a resident with a history of recurrent urinary tract infections (UTIs), neoplasm of the right kidney, and hypertension was prescribed Macrobid (nitrofurantoin) 100 mg daily as a prophylactic antibiotic for chronic UTIs. The physician's order for the antibiotic was open-ended, lacking a stop date, and was continued without documented evidence of current infection or symptoms. Medical records and progress notes indicated that the resident did not exhibit signs or symptoms of a UTI during the period the antibiotic was administered, and a urine dip was negative. There was also no documentation that a urinalysis was performed as ordered. The facility's antibiotic stewardship policy required that antibiotic orders include a duration of treatment, specifying start and stop dates or the number of days of therapy. The policy also emphasized monitoring antibiotic use and providing education on the risks associated with antibiotics. Despite this, the resident received ongoing prophylactic antibiotic treatment without adherence to these protocols, and the facility did not ensure that its antibiotic stewardship program included effective monitoring or protocols for antibiotic use as required.
Failure to Document and Offer Second Pneumococcal Vaccine Dose
Penalty
Summary
A deficiency was identified when the facility failed to offer or document the administration or declination of the second dose of the pneumococcal immunization series for one resident. The resident, who had a medical history including a right fibula fracture, congestive heart failure, chronic kidney disease, type 2 diabetes mellitus, a prosthetic heart valve, cardiomyopathy, and hypertension, had received the PCV-13 pneumococcal vaccine. However, there was no documentation in the medical record indicating that the resident was administered, offered, or declined the subsequent recommended pneumococcal vaccine. The facility's process involved the ADON checking the Statewide Immunization Information System for new admissions and completing a vaccine form. In this case, the resident's vaccination consent form was marked as "unable to determine" for the pneumococcal vaccine, and the DON confirmed that there was no evidence of the second vaccine being offered or declined. The facility's policy required assessment and offering of the pneumococcal vaccine series upon admission, with documentation of administration or refusal, but this was not followed for the resident in question.
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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 Clearfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rocky Mountain Care- Clearfield | 1.3 mi | ★★★★★ | 6 | 0 |
| Fairfield Village Rehabilitation | 3.7 mi | ★★★★★ | 1 | 0 |
| Heritage Park Healthcare And Rehabilitation | 5.7 mi | ★★★★★ | 0 | 0 |
| Pine View Transitional Rehab | 6.3 mi | ★★★★★ | 0 | 0 |
| The Terrace Transitional | 6.4 mi | ★★★★★ | 0 | 0 |
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