Cycle 1
Health 2024-03-14 · Fire 2024-03-14
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Orem, UT
Stonehenge of Orem
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
435 West Center Street, Orem, UT
(801) 850-5454
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
34
Certified beds
Average residents
27
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stonehenge Of Utah
Operator or chain grouping
Approved since
2009-01-12
CMS approved date
Coverage
Medicare
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.25
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
4.52
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
2.10
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.89
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.96
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.07
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
891
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.42
Composite VBP score used to determine payment impact.
Payment multiplier
1.0173
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.47
Baseline 19.46% · Performance 18.90% · Measure score 5.47 · Achievement 5.47 · Improvement 1.83
Healthcare-associated infections
7.58
Baseline 7.66% · Performance 5.57% · Measure score 7.58 · Achievement 7.58 · Improvement 7.34
Total nurse turnover
5.68
Baseline 52.78% · Performance 40.48% · Measure score 5.68 · Achievement 5.68 · Improvement 3.91
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.68% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 287 · Observed rate 5.23% · Lower 95% interval 6.3% |
| Discharge to community | 70.5% |
50.57%
19.9 pts better
|
Better than the National Rate · Eligible stays 276 · Observed rate 75% · Lower 95% interval 64.63% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 176 · Denominator 176 |
| Falls with major injury | 1.7% |
0.77%
0.9 pts worse
|
Numerator 3 · Denominator 176 |
| Discharge self-care score | 82.27% |
53.69%
28.6 pts better
|
Numerator 116 · Denominator 141 |
| Discharge mobility score | 57.45% |
50.94%
6.5 pts better
|
Numerator 81 · Denominator 141 |
| Pressure ulcers or injuries, new or worsened | 3.98% |
2.29%
1.7 pts worse
|
Numerator 7 · Denominator 176 · Adjusted rate 5.04% |
| Healthcare-associated infections requiring hospitalization | 5.57% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 183 · Observed rate 2.73% · Lower 95% interval 3.08% |
| Staff COVID-19 vaccination coverage | 0.88% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 114 |
| Staff flu vaccination coverage | 27.72% |
42%
14.3 pts worse
|
Numerator 56 · Denominator 202 |
| Discharge function score | 65.25% |
56.45%
8.8 pts better
|
Numerator 92 · Denominator 141 |
| Transfer of health information to provider | 98.6% |
95.95%
2.6 pts better
|
Numerator 141 · Denominator 143 |
| Transfer of health information to patient | 96.77% |
96.28%
0.5 pts better
|
Numerator 30 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 15 · Denominator 90 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.3%
6.7 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
11.8%
4.6 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 7.0% · Expected 11.0% · 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 | 98.9% |
91.0%
7.9 pts better
|
79.7%
19.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.0% |
17.4%
6.4 pts better
|
23.9%
12.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.0% · Observed 11.3% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-06 · Fire 2022-07-06
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2020-01-22 · Fire 2020-01-22
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-03-14
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 2024-03-25
D · Potential for more than minimal harm
2024-03-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-03-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-25
D · Potential for more than minimal harm
2022-07-06
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 2022-08-20
D · Potential for more than minimal harm
2020-01-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-03-27
D · Potential for more than minimal harm
2020-01-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-02-03
D · Potential for more than minimal harm
2020-01-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-02-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-03-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-25
Penalties and ownership
What sits behind the stars
Ownership
Stonehenge Of Orem, LLC
5% Or Greater Direct Ownership Interest · Organization
Campbell, Ben
5% Or Greater Indirect Ownership Interest · Individual
Carrera, Rory
5% Or Greater Indirect Ownership Interest · Individual
Carrera, Rory
Operational/Managerial Control · Individual
Cichos, Tyson
5% Or Greater Direct Ownership Interest · Individual
Cichos, Tyson
Limited Partnership Interest · Individual
Cloward, Wyatt
5% Or Greater Direct Ownership Interest · Individual
Robison, Cory
5% Or Greater Direct Ownership Interest · Individual
Robison, Cory
Operational/Managerial Control · Individual
Robison, Cory
Corporate Officer · Individual
Stevens, David
5% Or Greater Indirect Ownership Interest · Individual
Stevens, David
Operational/Managerial Control · Individual
Stonehenge Care LLC
Operational/Managerial Control · Organization
Stonehenge Of Orem, LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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Cascades at Orchard Park
Orem, UT
4-star overall rating with 3-star inspections with $11,992 in total fines with 4 recent health deficiencies
#2
Orem Rehabilitation and Nursing Center
Orem, UT
3-star overall rating with 2-star inspections with abuse icon flag with $38,357 in total fines with 10 recent health deficiencies
#3
Aspen Ridge of Utah Valley
Orem, UT
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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