Cycle 1
Health 2024-12-18 · Fire 2024-12-18
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
South Jordan, UT
Stonehenge of South Jordan
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1371 West South Jordan Parkway, South Jordan, UT
(801) 253-1370
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
32
Certified beds
Average residents
23
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stonehenge Of Utah
Operator or chain grouping
Approved since
2011-06-15
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
1.78
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
5.01
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
2.42
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.22
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
1.17
Weekend registered nurse coverage · state 0.84 · national 0.47
Physical therapist
0.25
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
1.56
CMS adjusted RN staffing hours
Adjusted total hours
4.39
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
258
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
75.42
Composite VBP score used to determine payment impact.
Payment multiplier
1.0246
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.54
Baseline 19.73% · Performance 17.47% · Measure score 8.54 · Achievement 8.54 · Improvement 7.86
Healthcare-associated infections
9.47
Baseline 6.54% · Performance 5.00% · Measure score 9.47 · Achievement 9.47 · Improvement 9
Total nurse turnover
4.61
Baseline 48.28% · Performance 44.83% · Measure score 4.61 · Achievement 4.61 · Improvement 0.97
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 | 7.18% |
10.72%
3.5 pts better
|
Better than the National Rate · Eligible stays 388 · Observed rate 3.61% · Lower 95% interval 5.47% |
| Discharge to community | 73.8% |
50.57%
23.2 pts better
|
Better than the National Rate · Eligible stays 356 · Observed rate 78.37% · Lower 95% interval 70.2% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.58% |
95.27%
4.3 pts better
|
Numerator 237 · Denominator 238 |
| Falls with major injury | 0.84% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 238 |
| Discharge self-care score | 44.89% |
53.69%
8.8 pts worse
|
Numerator 79 · Denominator 176 |
| Discharge mobility score | 43.18% |
50.94%
7.8 pts worse
|
Numerator 76 · Denominator 176 |
| Pressure ulcers or injuries, new or worsened | 2.94% |
2.29%
0.6 pts worse
|
Numerator 7 · Denominator 238 · Adjusted rate 4.86% |
| Healthcare-associated infections requiring hospitalization | 5% |
7.12%
2.1 pts better
|
No Different than the National Rate · Eligible stays 235 · Observed rate 2.13% · Lower 95% interval 2.97% |
| Staff COVID-19 vaccination coverage | 10.34% |
8.2%
2.1 pts better
|
Numerator 9 · Denominator 87 |
| Staff flu vaccination coverage | 65.59% |
42%
23.6 pts better
|
Numerator 61 · Denominator 93 |
| Discharge function score | 37.5% |
56.45%
19 pts worse
|
Numerator 66 · Denominator 176 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 120 · Denominator 120 |
| Transfer of health information to patient | 99.1% |
96.28%
2.8 pts better
|
Numerator 110 · Denominator 111 |
| Resident COVID-19 vaccinations up to date | 43.65% |
25.2%
18.4 pts better
|
Numerator 55 · Denominator 126 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
93.3%
6.6 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| 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 12.7% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
0.9%
0.6 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
91.0%
8.2 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
17.4%
1.1 pts worse
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 15.5% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-30 · Fire 2023-03-30
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-06-17 · Fire 2021-06-17
6 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-01-03
D · Potential for more than minimal harm
2024-12-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-03
F · Potential for more than minimal harm
2023-03-30
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-03-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-03-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-03-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-03-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-19
D · Potential for more than minimal harm
2021-06-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-07-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-18
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 2025-02-15
D · Potential for more than minimal harm
2024-12-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-31
G · Actual harm
2021-06-17
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 2021-07-16
F · Potential for more than minimal harm
2021-06-17
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 2021-07-16
E · Potential for more than minimal harm
2021-06-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-16
D · Potential for more than minimal harm
2021-06-17
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 2021-07-16
D · Potential for more than minimal harm
2021-06-17
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 2021-07-16
D · Potential for more than minimal harm
2021-06-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-07-16
Penalties and ownership
What sits behind the stars
Ownership
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 Indirect Ownership Interest · Individual
Cloward, Wyatt
5% Or Greater Direct Ownership Interest · Individual
Cloward, Wyatt
Operational/Managerial Control · Individual
Cloward, Wyatt
Corporate Officer · Individual
Embley, Eric
5% Or Greater Indirect Ownership Interest · Individual
Embley, Eric
Operational/Managerial Control · Individual
Geode Capital LLC
5% Or Greater Direct Ownership Interest · Organization
Robison, Cory
5% Or Greater Direct Ownership Interest · Individual
Robison, Cory
Operational/Managerial Control · Individual
Robison, Cory
Corporate Officer · Individual
Stonehenge Care LLC
5% Or Greater Indirect Ownership Interest · Organization
Stonehenge Care LLC
Operational/Managerial Control · Organization
Stonehenge Of Salt Lake LLC
5% Or Greater Indirect Ownership Interest · Organization
Stonehenge Of South Jordan LLC
5% Or Greater Direct Ownership Interest · Organization
Stonehenge Of South Jordan LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Sandy Health and Rehab
Sandy, UT
1-star overall rating with 1-star inspections with $89,798 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Copper Ridge Health Care
West Jordan, UT
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Rocky Mountain Care - Riverton
Riverton, UT
4-star overall rating with 3-star inspections with $33,212 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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