Cycle 1
Health 2025-07-23 · Fire 2025-07-23
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
American Fork, UT
Stonehenge of American Fork
4-star overall rating with 4-star inspections with $21,590 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
538 South 500 East, American Fork, UT
(801) 642-2000
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
119
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stonehenge Of Utah
Operator or chain grouping
Approved since
2012-09-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 5 overall / 4 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.41
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.45
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
4.36
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.80
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.08
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.33
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,081
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.1
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.55% · Performance 22.72% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.10
Baseline 7.59% · Performance 6.91% · Measure score 3.10 · Achievement 3.10 · Improvement 2.12
Total nurse turnover
2.27
Baseline 49.09% · Performance 54.40% · Measure score 2.27 · Achievement 2.27 · Improvement 0
Adjusted total nurse staffing
1.87
Baseline 3.77 hours · Performance 3.61 hours · Measure score 1.87 · Achievement 1.87 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.73% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 270 · Observed rate 8.52% · Lower 95% interval 7.06% |
| Discharge to community | 62.93% |
50.57%
12.4 pts better
|
Better than the National Rate · Eligible stays 239 · Observed rate 63.6% · Lower 95% interval 57.23% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.25% |
95.27%
3 pts better
|
Numerator 168 · Denominator 171 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 171 |
| Discharge self-care score | 42.52% |
53.69%
11.2 pts worse
|
Numerator 54 · Denominator 127 |
| Discharge mobility score | 31.5% |
50.94%
19.4 pts worse
|
Numerator 40 · Denominator 127 |
| Pressure ulcers or injuries, new or worsened | 1.75% |
2.29%
0.5 pts better
|
Numerator 3 · Denominator 171 · Adjusted rate 1.58% |
| Healthcare-associated infections requiring hospitalization | 6.91% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 151 · Observed rate 5.96% · Lower 95% interval 4.56% |
| Staff COVID-19 vaccination coverage | 2.2% |
8.2%
6 pts worse
|
Numerator 4 · Denominator 182 |
| Staff flu vaccination coverage | 24.39% |
42%
17.6 pts worse
|
Numerator 60 · Denominator 246 |
| Discharge function score | 18.11% |
56.45%
38.3 pts worse
|
Numerator 23 · Denominator 127 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 38 · Denominator 38 |
| Transfer of health information to patient | 99.06% |
96.28%
2.8 pts better
|
Numerator 105 · Denominator 106 |
| Resident COVID-19 vaccinations up to date | 15.22% |
25.2%
10 pts worse
|
Numerator 14 · Denominator 92 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.2
0.8 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.3 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.5
0.3 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
96.8%
3.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.5% |
98.0%
1.5 pts worse
|
95.5%
1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
2.6%
0.3 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.7% · Q3 1.8% · Q4 1.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
16.1%
13.8 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 3.6% · Q4 1.9% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
3.8%
1.3 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 0.0% · Q3 6.1% · Q4 4.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.9% |
24.1%
0.8 pts worse
|
19.6%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 24.0% · Q3 26.5% · Q4 22.0% · 4Q avg 24.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.3% |
15.4%
3.1 pts better
|
16.7%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 14.6% · Q3 15.4% · Q4 10.3% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 34.7% |
18.3%
16.4 pts worse
|
16.3%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
13.6%
0.9 pts worse
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 9.1% · Q3 15.9% · Q4 4.4% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
1.8%
1.4 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 0.0% · Q3 3.6% · Q4 3.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.0% |
22.4%
5.6 pts worse
|
19.8%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 33.3% · Q3 28.5% · Q4 19.7% · 4Q avg 28.0% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.1%
0.4 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 6.6% · Q3 4.6% · Q4 2.2% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
93.3%
4.4 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 97.3% · Q3 98.8% · Q4 98.8% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.4% |
11.8%
2.6 pts worse
|
12.0%
2.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 14.3% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
0.9%
0.5 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.5% · Q3 2.6% · Q4 0.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.2% |
91.0%
4.2 pts better
|
79.7%
15.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
17.4%
8 pts worse
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 26.0% · Expected 24.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-10 · Fire 2023-10-10
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-11-18 · Fire 2021-11-18
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-23
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 2025-08-29
D · 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 2025-08-29
D · Potential for more than minimal harm
2023-10-10
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 2023-10-30
D · Potential for more than minimal harm
2023-10-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-30
E · Potential for more than minimal harm
2021-11-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-11-18
D · Potential for more than minimal harm
2021-11-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-11-23
D · Potential for more than minimal harm
2021-11-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-10
Inspection history
Recent health citations
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 2025-08-29
D · Potential for more than minimal harm
2025-07-23
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-23
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-07-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-29
G · Actual harm
2023-10-10
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 2023-10-30
F · Potential for more than minimal harm
2023-10-10
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 2023-10-25
D · Potential for more than minimal harm
2023-10-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-25
G · Actual harm
2021-11-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-01-07
E · Potential for more than minimal harm
2021-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-18
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2022-01-07
D · Potential for more than minimal harm
2021-11-18
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 2022-01-07
Penalties and ownership
What sits behind the stars
$21,590
2023-10-10
Fine
Fine · fine $21,590
Fine
Ownership
Robison, Cory
5% Or Greater Indirect Ownership Interest · Individual
Carrera, Rory
Operational/Managerial Control · Individual
Cichos, Tyson
5% Or Greater Direct Ownership Interest · Individual
Cichos, Tyson
Operational/Managerial Control · Individual
Cloward, Wyatt
5% Or Greater Direct Ownership Interest · Individual
Cloward, Wyatt
Operational/Managerial Control · Individual
Gillespie, Deborah
Operational/Managerial Control · Individual
Howells, Stephen
Operational/Managerial Control · Individual
Kane County Human Resource Special Service District
5% Or Greater Direct Ownership Interest · Organization
Kane County Human Resource Special Service District
Operational/Managerial Control · Organization
Keele, Kacie
Operational/Managerial Control · Individual
Loveless, Kurt
Operational/Managerial Control · Individual
Robison, Cory
Operational/Managerial Control · Individual
Stonehenge Of American Fork, Lc
5% Or Greater Direct Ownership Interest · Organization
Stonehenge Of American Fork, Lc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Monument Healthcare American Fork
American Fork, UT
3-star overall rating with 2-star inspections with $35,437 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Mission at Alpine Rehabilitation Center
Pleasant Grove, UT
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $125,737 in total fines with 30 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Stonehenge of Orem
Orem, UT
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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