CLEARFIELD, UTAH — The family of a 66-year-old former Walmart greeter has filed a wrongful death lawsuit against Rocky Mountain Care Clearfield, alleging that chronic understaffing and institutional neglect led to her death from preventable pressure sores and infections, according to a report by ABC4 News.
Tamara Bircumshaw, described by her family as a beloved community fixture known for greeting shoppers at her local Walmart, died after developing severe pressure ulcers and subsequent infections while residing at the 168-bed facility in Clearfield, as reported by ABC4. The lawsuit claims that Rocky Mountain Care received approximately $2.9 million in federal funding yet allegedly failed to maintain adequate staffing levels to provide basic care to its residents.
"It shattered us," a family member stated, according to ABC4's reporting on the case.
Allegations of Systemic Neglect
The lawsuit paints a picture of a facility that was allegedly stretched far beyond its capacity to deliver safe care. According to ABC4, Rocky Mountain Care Clearfield housed roughly twice the number of residents found in a typical Utah nursing facility, yet the suit claims staffing levels did not scale to meet that demand. The family alleges that this imbalance directly contributed to Bircumshaw's deteriorating condition, as caregivers were reportedly unable to provide the repositioning, wound monitoring, and hygiene protocols necessary to prevent pressure injuries.
Pressure ulcers — commonly known as bedsores — develop when sustained pressure restricts blood flow to the skin, typically in patients who are immobile or have limited mobility. Federal regulations under the Centers for Medicare & Medicaid Services require nursing facilities to ensure that residents who enter without pressure sores do not develop them unless clinically unavoidable, and that residents with existing sores receive treatment to promote healing and prevent infection.
The progression from pressure sore to fatal infection suggests a prolonged period during which intervention could have altered the outcome, a pattern that the family's legal team argues reflects systemic care failures rather than an isolated incident.
CMS Inspection History
Federal inspection data from the Centers for Medicare & Medicaid Services reveals a facility with a troubled regulatory track record that provides important context for the family's allegations. Rocky Mountain Care Clearfield currently holds an overall rating of just 2 out of 5 stars in the CMS rating system, with its health inspection score at the lowest possible mark — 1 out of 5 stars. The facility's staffing rating sits at 2 out of 5 stars.
Across 11 inspections on record with CMS, the facility has accumulated 74 total deficiencies. Notably, the most recent inspection on March 27, 2025, cited the facility for failing to immediately notify residents, their physicians, and family members of situations involving injury or decline — a deficiency classified at severity level D, indicating potential for more than minimal harm.
That same notification deficiency was also cited during a January 2023 inspection, suggesting a recurring pattern. That same January 2023 survey also found the facility failed to ensure residents were free from significant medication errors — a more serious deficiency rated at severity level G, indicating actual harm to a resident.
An August 2022 inspection flagged the facility for failing to honor residents' rights to a safe, clean, and homelike environment at severity level E, as well as failures in developing complete care plans within the federally required seven-day window following comprehensive assessments.
While the facility's quality measures rating stands at 5 out of 5 stars, health policy researchers have noted that quality measure scores are largely self-reported by facilities, whereas health inspection ratings reflect direct observations by state surveyors.
Ownership & Operations
Rocky Mountain Care Clearfield is classified as a non-profit corporation under CMS records. Rocky Mountain Care operates multiple long-term care facilities across Utah. The $2.9 million in federal funding cited in the lawsuit, as reported by ABC4, underscores the significant taxpayer investment in the facility's operations — funding that the family argues was not translated into adequate bedside care for residents like Bircumshaw.
The legal action raises broader questions about oversight mechanisms for facilities that receive substantial public funding while maintaining below-average inspection ratings over extended periods.
Resources for Families
Families with concerns about care quality at any Utah nursing facility have several avenues for reporting and assistance. The Utah Long-Term Care Ombudsman program can be reached at 1-800-541-7735 and serves as an independent advocate for residents of nursing homes and assisted living facilities. The ombudsman program investigates complaints, mediates disputes, and can help families navigate the regulatory system.
The national eldercare hotline at 1-800-677-1116 connects callers with local resources and reporting agencies. Additional information about resident rights and how to file complaints is available through the National Long-Term Care Ombudsman Resource Center at [ltcombudsman.org](https://ltcombudsman.org).
Families are encouraged to document concerns in writing, request copies of inspection reports, and attend care plan meetings. Any suspected abuse or neglect should be reported immediately to both the ombudsman program and the facility's administration.