Cycle 1
Health 2025-07-23 · Fire 2025-07-23
13 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Clearfield, UT
Thatcher Brook Rehabilitation & Care Center
5-star overall rating with 3-star inspections with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1795 South Chelemes Way, Clearfield, UT
(801) 614-5700
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
27
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2009-04-16
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.64
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
3.02
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
5.90
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
2.87
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.68
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.09
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.33
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.61
CMS adjusted RN staffing hours
Adjusted total hours
5.78
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,105
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.01
Composite VBP score used to determine payment impact.
Payment multiplier
0.9993
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.90
Baseline 23.89% · Performance 18.13% · Measure score 7.90 · Achievement 7.13 · Improvement 7.90
Healthcare-associated infections
2.33
Baseline 5.63% · Performance 7.14% · Measure score 2.33 · Achievement 2.33 · Improvement 0
Total nurse turnover
2.23
Performance 54.55% · Measure score 2.23 · Achievement 2.23 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.94
Performance 4.77 hours · Measure score 5.94 · Achievement 5.94 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.72% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 220 · Observed rate 7.73% · Lower 95% interval 6.52% |
| Discharge to community | 68.93% |
50.57%
18.4 pts better
|
Better than the National Rate · Eligible stays 211 · Observed rate 72.04% · Lower 95% interval 62.98% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.7% |
95.27%
3.4 pts better
|
Numerator 152 · Denominator 154 |
| Falls with major injury | 0.65% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 154 |
| Discharge self-care score | 71.82% |
53.69%
18.1 pts better
|
Numerator 79 · Denominator 110 |
| Discharge mobility score | 84.55% |
50.94%
33.6 pts better
|
Numerator 93 · Denominator 110 |
| Pressure ulcers or injuries, new or worsened | 1.95% |
2.29%
0.3 pts better
|
Numerator 3 · Denominator 154 · Adjusted rate 2.18% |
| Healthcare-associated infections requiring hospitalization | 7.14% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 145 · Observed rate 6.21% · Lower 95% interval 4.78% |
| Staff COVID-19 vaccination coverage | 7.32% |
8.2%
0.9 pts worse
|
Numerator 6 · Denominator 82 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 77.27% |
56.45%
20.8 pts better
|
Numerator 85 · Denominator 110 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 109 · Denominator 109 |
| Transfer of health information to patient | 97.3% |
96.28%
1 pts better
|
Numerator 36 · Denominator 37 |
| Resident COVID-19 vaccinations up to date | 46.38% |
25.2%
21.2 pts better
|
Numerator 32 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
93.3%
5.4 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 99.3% · Q3 99.4% · Q4 98.8% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
11.8%
3 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 9.5% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
0.9%
0.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.8% |
91.0%
3.8 pts better
|
79.7%
15.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
17.4%
5.3 pts worse
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 25.4% · Expected 26.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-27 · Fire 2023-09-27
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-06-23 · Fire 2022-06-23
10 health deficiencies
Top issue: Infection Control (4 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-08-12
F · Potential for more than minimal harm
2025-07-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-08-12
E · Potential for more than minimal harm
2025-07-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-07-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-08-12
D · Potential for more than minimal harm
2025-07-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-12
E · Potential for more than minimal harm
2023-09-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-19
E · Potential for more than minimal harm
2023-09-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-19
E · Potential for more than minimal harm
2023-09-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-10-19
D · Potential for more than minimal harm
2023-09-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-19
D · Potential for more than minimal harm
2023-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-26
D · Potential for more than minimal harm
2023-09-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-19
E · Potential for more than minimal harm
2022-06-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-08-01
E · Potential for more than minimal harm
2022-06-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-08-13
E · Potential for more than minimal harm
2025-07-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-08-18
E · Potential for more than minimal harm
2025-07-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-18
E · Potential for more than minimal harm
2025-07-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-08-13
D · Potential for more than minimal harm
2025-07-23
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-13
D · Potential for more than minimal harm
2025-07-23
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-08-13
D · Potential for more than minimal harm
2025-07-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-13
D · Potential for more than minimal harm
2025-07-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-08-13
D · Potential for more than minimal harm
2025-07-23
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-08-19
D · Potential for more than minimal harm
2025-07-23
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-23
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-08-18
F · Potential for more than minimal harm
2022-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-01
E · Potential for more than minimal harm
2022-06-23
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-08-01
E · Potential for more than minimal harm
2022-06-23
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-08-01
Penalties and ownership
What sits behind the stars
Ownership
Stucki, Ron
5% Or Greater Direct Ownership Interest · Individual
Compas, David
5% Or Greater Direct Ownership Interest · Individual
Wilcox, John
5% Or Greater Direct Ownership Interest · Individual
Compas, David
Corporate Director · Individual
Pulham, Randy
5% Or Greater Direct Ownership Interest · Individual
Pulham, Randy
Corporate Director · Individual
Stucki, Ron
Corporate Director · Individual
Wilcox, John
Corporate Director · Individual
Nearby options
Other facilities in reach
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Rocky Mountain Care- Clearfield
Clearfield, UT
2-star overall rating with 1-star inspections with $58,637 in total fines with 19 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Fairfield Village Rehabilitation
Layton, UT
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Heritage Park Healthcare and Rehabilitation
Roy, UT
3-star overall rating with 2-star inspections with abuse icon flag with $36,645 in total fines with 12 recent health deficiencies
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