THATCHER BROOK REHABILITATION AND CARE - CLEARFIELD, UT

Quality Measures

Staff Information

Complaint Deficiency

• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Properly located and lighted Exit signs
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Properly maintained smoke detectors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Portable fire extinguishers
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Restrictions on the use of portable space heaters
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Other fire safety features required by fire safety codes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Weekly inspections and monthly testing of generators
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• A properly installed and maintained dumbwaiter or escalator
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Allow residents to easily view the results of the nursing home's most recent survey
  • Harm: Potential for minimal harm
  • Scope: Many
• Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Provide activities to meet the interests and needs of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure each resident receives an accurate assessment by a qualified health professional
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Maintain 15 months of resident assessments in the resident's active clinical record
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Actual harm
  • Scope: Many
• Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
  • Harm: Potential for minimal harm
  • Scope: Some
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Keep all essential equipment working safely
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Make sure that a working call system is available in each resident's room or bathroom and bathing area
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Be administered in an acceptable way that maintains the well-being of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• 1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compensation
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Give or get quality lab services/tests in a timely manner to meet the needs of residents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Allow the resident the right to participate in the planning or revision of the resident's care plan
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that residents are safe from serious medication errors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Keep accurate, complete and organized clinical records on each resident that meet professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few