Cycle 1
Health 2024-06-27 · Fire 2024-06-27
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Washington Terrace, UT
Stonehenge of Ogden
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
5648 South Adams Avenue, Washington Terrace, UT
(801) 475-0500
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
52
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stonehenge Of Utah
Operator or chain grouping
Approved since
2015-01-21
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
1.16
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
4.48
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.96
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.87
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
33%
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
4,036
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.60
Composite VBP score used to determine payment impact.
Payment multiplier
0.9945
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.20
Baseline 16.44% · Performance 18.09% · Measure score 7.20 · Achievement 7.20 · Improvement 0
Healthcare-associated infections
4.51
Baseline 5.01% · Performance 6.49% · Measure score 4.51 · Achievement 4.51 · Improvement 0
Total nurse turnover
0.65
Baseline 55.56% · Performance 61.02% · Measure score 0.65 · Achievement 0.65 · Improvement 0
Adjusted total nurse staffing
4.28
Baseline 3.99 hours · Performance 4.29 hours · Measure score 4.28 · Achievement 4.28 · Improvement 1.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.67% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 259 · Observed rate 7.34% · Lower 95% interval 7.27% |
| Discharge to community | 60.55% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 249 · Observed rate 63.05% · Lower 95% interval 54.37% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 153 · Denominator 153 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 153 |
| Discharge self-care score | 74.6% |
53.69%
20.9 pts better
|
Numerator 94 · Denominator 126 |
| Discharge mobility score | 84.13% |
50.94%
33.2 pts better
|
Numerator 106 · Denominator 126 |
| Pressure ulcers or injuries, new or worsened | 1.31% |
2.29%
1 pts better
|
Numerator 2 · Denominator 153 · Adjusted rate 1.96% |
| Healthcare-associated infections requiring hospitalization | 6.49% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 145 · Observed rate 4.14% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 1.64% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 122 |
| Staff flu vaccination coverage | 44.37% |
42%
2.4 pts better
|
Numerator 63 · Denominator 142 |
| Discharge function score | 77.78% |
56.45%
21.3 pts better
|
Numerator 98 · Denominator 126 |
| Transfer of health information to provider | 96.06% |
95.95%
0.1 pts better
|
Numerator 122 · Denominator 127 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 57.14% |
25.2%
31.9 pts better
|
Numerator 48 · Denominator 84 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.5% |
98.0%
7.5 pts worse
|
95.5%
5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
2.6%
1.2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
16.1%
16.1 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 1.5% |
3.8%
2.3 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.3% |
24.1%
19.8 pts better
|
19.6%
15.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
15.4%
15.4 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.1% |
18.3%
6.8 pts worse
|
16.3%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.3% |
13.6%
0.7 pts worse
|
14.9%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.8%
0.4 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.2% |
22.4%
1.2 pts better
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.1%
0.2 pts worse
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 4.3% · 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 99.0% · Q2 99.1% · Q3 100.0% · Q4 98.2% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.1% |
11.8%
2.3 pts worse
|
12.0%
2.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 12.3% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
0.9%
About the same
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.6% · Q3 0.6% · Q4 1.3% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.4% |
91.0%
4.4 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.2% |
17.4%
0.8 pts worse
|
23.9%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 15.9% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-01-11 · Fire 2023-01-11
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-09-02 · Fire 2021-09-02
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-06-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-08
D · Potential for more than minimal harm
2023-01-11
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 2023-03-11
D · Potential for more than minimal harm
2023-01-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-06-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-16
E · Potential for more than minimal harm
2024-06-27
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 2024-08-16
D · Potential for more than minimal harm
2024-06-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-06-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-08-16
D · Potential for more than minimal harm
2023-01-11
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-01-11
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-01-11
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 2023-03-03
D · Potential for more than minimal harm
2023-01-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-01-11
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-01-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-03
E · Potential for more than minimal harm
2021-09-02
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2021-10-19
D · Potential for more than minimal harm
2021-09-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-19
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
Gillespie, Deborah
W-2 Managing Employee · Individual
Howells, Stephen
Corporate Officer · Individual
Loveless, Kurt
Operational/Managerial Control · Individual
Loveless, Kurt
Corporate Officer · Individual
Robison, Cory
Operational/Managerial Control · Individual
Robison, Cory
W-2 Managing Employee · Individual
Stonehenge Of Ogden LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Mt Ogden Health and Rehabilitation Center
Washington Terrace, UT
4-star overall rating with 4-star inspections with 5 recent health deficiencies
#2
The Terrace Transitional
Ogden, UT
3-star overall rating with 2-star inspections with 14 recent health deficiencies
#3
Crestwood Rehabilitation and Nursing
Ogden, UT
2-star overall rating with 1-star inspections with $20,013 in total fines with 16 recent health deficiencies
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