Cycle 1
Health 2023-11-30 · Fire 2023-11-30
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cedar City, UT
Stonehenge of Cedar City
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
333 West 1425 North, Cedar City, UT
(435) 267-1700
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stonehenge Of Utah
Operator or chain grouping
Approved since
2003-05-01
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
1.00
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
4.33
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.83
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.05
CMS adjusted RN staffing hours
Adjusted total hours
4.57
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
11%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,473
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9896
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.92
Baseline 18.89% · Performance 19.62% · Measure score 3.92 · Achievement 3.92 · Improvement 0
Healthcare-associated infections
5.21
Baseline 5.45% · Performance 6.28% · Measure score 5.21 · Achievement 5.21 · Improvement 0
Total nurse turnover
1.36
Baseline 48.53% · Performance 58.11% · Measure score 1.36 · Achievement 1.36 · Improvement 0
Adjusted total nurse staffing
3.93
Baseline 3.93 hours · Performance 4.20 hours · Measure score 3.93 · Achievement 3.93 · Improvement 0.95
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.03% |
10.72%
2.7 pts better
|
No Different than the National Rate · Eligible stays 177 · Observed rate 3.39% · Lower 95% interval 5.45% |
| Discharge to community | 68.39% |
50.57%
17.8 pts better
|
Better than the National Rate · Eligible stays 173 · Observed rate 73.41% · Lower 95% interval 60.92% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.75% |
95.27%
3.5 pts better
|
Numerator 79 · Denominator 80 |
| Falls with major injury | 1.25% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 80 |
| Discharge self-care score | 59.7% |
53.69%
6 pts better
|
Numerator 40 · Denominator 67 |
| Discharge mobility score | 62.69% |
50.94%
11.8 pts better
|
Numerator 42 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 3.75% |
2.29%
1.5 pts worse
|
Numerator 3 · Denominator 80 · Adjusted rate 5.73% |
| Healthcare-associated infections requiring hospitalization | 6.28% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 3.26% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 2.36% |
8.2%
5.8 pts worse
|
Numerator 3 · Denominator 127 |
| Staff flu vaccination coverage | 35.43% |
42%
6.6 pts worse
|
Numerator 62 · Denominator 175 |
| Discharge function score | 56.72% |
56.45%
0.3 pts better
|
Numerator 38 · Denominator 67 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 59 · Denominator 59 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 15.38% |
25.2%
9.8 pts worse
|
Numerator 6 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.4 · 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 | 100.0% |
98.0%
2 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
2.6%
1 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 6.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
16.1%
15.3 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 12.3% |
3.8%
8.5 pts worse
|
5.4%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 12.5% · Q3 6.9% · Q4 10.3% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
24.1%
13.4 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 9.4% · Q3 6.9% · Q4 10.3% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.3% |
15.4%
12.1 pts better
|
16.7%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 4.3% · Q3 0.0% · Q4 0.0% · 4Q avg 3.3% · 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 | 34.6% |
18.3%
16.3 pts worse
|
16.3%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 29.6% · 4Q avg 34.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.6% |
13.6%
12 pts worse
|
14.9%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 29.0% · Q3 39.3% · Q4 21.4% · 4Q avg 25.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.9%
0.7 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · 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 9.1% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
22.4%
4.7 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 35.0% · Q3 25.1% · Q4 37.0% · 4Q avg 27.1% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
4.1%
0.2 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.8% · Q3 3.2% · Q4 3.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
93.3%
5.8 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.1% · Q3 98.4% · Q4 100.0% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.7% |
11.8%
4.9 pts worse
|
12.0%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 16.0% · Expected 10.7% · 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 | 96.3% |
91.0%
5.3 pts better
|
79.7%
16.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.4% |
17.4%
1 pts better
|
23.9%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 14.8% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-01 · Fire 2021-12-01
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-09-11 · Fire 2019-09-11
9 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-11-30
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-02-01
D · Potential for more than minimal harm
2021-12-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-01-07
E · Potential for more than minimal harm
2019-09-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-10-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-05
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 2025-03-17
D · Potential for more than minimal harm
2023-11-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-20
F · Potential for more than minimal harm
2021-12-01
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2022-01-28
D · Potential for more than minimal harm
2021-12-01
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-01-28
D · Potential for more than minimal harm
2021-12-01
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 2022-01-28
D · Potential for more than minimal harm
2021-12-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-01-24
D · Potential for more than minimal harm
2021-12-01
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 2022-01-28
D · Potential for more than minimal harm
2021-12-01
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 2022-01-28
D · Potential for more than minimal harm
2021-12-01
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-01-28
D · Potential for more than minimal harm
2021-12-01
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-01-28
G · Actual harm
2019-09-11
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 2019-11-01
G · Actual harm
2019-09-11
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-11-01
E · Potential for more than minimal harm
2019-09-11
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 2019-11-01
D · Potential for more than minimal harm
2019-09-11
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 2019-11-01
D · Potential for more than minimal harm
2019-09-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-11
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-11
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2019-10-31
D · Potential for more than minimal harm
2019-09-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-01
Penalties and ownership
What sits behind the stars
Ownership
Kane County Human Resource Special Service District
5% Or Greater Direct Ownership Interest · Organization
Gillespie, Deborah
Operational/Managerial Control · Individual
Howells, Stephen
Operational/Managerial Control · Individual
Howells, Stephen
Corporate Officer · Individual
Loveless, Kurt
Operational/Managerial Control · Individual
Loveless, Kurt
Corporate Officer · Individual
Robison, Cory
Operational/Managerial Control · Individual
Stonehenge Of Cedar Cityut Inc
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Cedar Health and Rehabilitation
Cedar City, UT
2-star overall rating with 2-star inspections with 10 recent health deficiencies
#2
Garfield County Nursing Home
Panguitch, UT
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Hurricane Health and Rehabilitation
Hurricane, UT
2-star overall rating with 2-star inspections with $46,602 in total fines with 7 recent health deficiencies
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