Cycle 1
Health 2025-03-05 · Fire 2025-03-05
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Springville, UT
Stonehenge of Springville
4-star overall rating with 4-star inspections with $4,938 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
909 West 450 South, Springville, UT
(801) 489-1900
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
39
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Stonehenge Of Utah
Operator or chain grouping
Approved since
1992-09-11
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
1.30
Registered nurse staffing · state 1.19 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.51 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.37 · national 2.35
Total nurse hours
4.22
All reported nurse hours · state 4.06 · national 3.89
Licensed hours
1.81
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.60
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.91
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
1.24
CMS adjusted RN staffing hours
Adjusted total hours
4.01
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
55%
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
5,786
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9888
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.73
Baseline 22.22% · Performance 19.50% · Measure score 4.73 · Achievement 4.16 · Improvement 4.73
Healthcare-associated infections
5.77
Baseline 6.09% · Performance 6.11% · Measure score 5.77 · Achievement 5.77 · Improvement 0
Total nurse turnover
0.58
Baseline 55.77% · Performance 61.29% · Measure score 0.58 · Achievement 0.58 · Improvement 0
Adjusted total nurse staffing
2.93
Baseline 3.78 hours · Performance 3.91 hours · Measure score 2.93 · Achievement 2.93 · Improvement 0.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.16% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 155 · Observed rate 8.39% · Lower 95% interval 7.06% |
| Discharge to community | 63.13% |
50.57%
12.6 pts better
|
Better than the National Rate · Eligible stays 135 · Observed rate 65.93% · Lower 95% interval 55.95% |
| Medicare spending per beneficiary | 0.85 |
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 | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 80 |
| Discharge self-care score | 26.09% |
53.69%
27.6 pts worse
|
Numerator 12 · Denominator 46 |
| Discharge mobility score | 80.43% |
50.94%
29.5 pts better
|
Numerator 37 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 2 · Denominator 80 · Adjusted rate 3.29% |
| Healthcare-associated infections requiring hospitalization | 6.11% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 3.53% · Lower 95% interval 3.22% |
| Staff COVID-19 vaccination coverage | 3.57% |
8.2%
4.6 pts worse
|
Numerator 3 · Denominator 84 |
| Staff flu vaccination coverage | 36.67% |
42%
5.3 pts worse
|
Numerator 44 · Denominator 120 |
| Discharge function score | 69.57% |
56.45%
13.1 pts better
|
Numerator 32 · Denominator 46 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 58 · Denominator 58 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 11.11% |
25.2%
14.1 pts worse
|
Numerator 5 · Denominator 45 |
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% · 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 | 3.6% |
2.6%
1 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.9% · Q4 7.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.6% |
16.1%
10.5 pts better
|
11.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 0.0% · Q3 10.7% · Q4 3.6% · 4Q avg 5.6% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
3.8%
2.9 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 8.0% · Q3 7.1% · Q4 7.7% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.8% |
24.1%
9.3 pts better
|
19.6%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 14.8% · Q3 14.3% · Q4 15.4% · 4Q avg 14.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.4% |
15.4%
11 pts better
|
16.7%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.4% · 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 | 28.4% |
18.3%
10.1 pts worse
|
16.3%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.7% |
13.6%
13.1 pts worse
|
14.9%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 12.0% · Q3 25.9% · Q4 36.0% · 4Q avg 26.7% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
1.8%
1.9 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 4.0% · Q3 0.0% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.9% |
22.4%
0.5 pts better
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 13.5% · Q3 16.8% · Q4 22.4% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.1%
0.5 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.2% · Q4 7.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.8% |
93.3%
3.5 pts worse
|
81.7%
8.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.4% · Q2 90.8% · Q3 86.5% · Q4 90.8% · 4Q avg 89.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.4% |
11.8%
6.6 pts worse
|
12.0%
6.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 18.8% · Expected 11.4% · 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 | 90.0% |
91.0%
1 pts worse
|
79.7%
10.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
17.4%
7.8 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 23.2% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-17 · Fire 2023-05-17
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2021-08-05 · Fire 2021-08-05
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-05
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 2025-03-12
D · Potential for more than minimal harm
2025-03-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-03-05
D · Potential for more than minimal harm
2023-05-17
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-01
D · Potential for more than minimal harm
2023-05-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-01
E · Potential for more than minimal harm
2021-08-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-09-30
Inspection history
Recent health citations
G · Actual harm
2025-03-05
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 2025-04-04
D · Potential for more than minimal harm
2025-03-05
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 2025-04-04
D · Potential for more than minimal harm
2025-03-05
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 2025-04-04
D · Potential for more than minimal harm
2025-03-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-04
F · Potential for more than minimal harm
2021-08-05
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2021-09-30
E · Potential for more than minimal harm
2021-08-05
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-09-30
E · Potential for more than minimal harm
2021-08-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-09-30
D · Potential for more than minimal harm
2021-08-05
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 2021-09-30
D · Potential for more than minimal harm
2021-08-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-09-30
D · Potential for more than minimal harm
2021-08-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-09-30
Penalties and ownership
What sits behind the stars
$1,764
2023-09-18
Fine
Fine · fine $1,764
Fine
$3,174
2023-08-28
Fine
Fine · fine $3,174
Fine
Ownership
Kane County Human Resource Special Service District
5% Or Greater Direct Ownership Interest · Organization
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
Operational/Managerial Control · Individual
Cloward, Wyatt
5% Or Greater Direct Ownership Interest · Individual
Cloward, Wyatt
Operational/Managerial Control · Individual
Gillespie, Deborah
5% Or Greater Indirect Ownership Interest · Individual
Gillespie, Deborah
Operational/Managerial Control · Individual
Howells, Stephen
5% Or Greater Indirect Ownership Interest · Individual
Howells, Stephen
Operational/Managerial Control · Individual
Howells, Stephen
Corporate Officer · Individual
Kane County Human Resource Special Service District
Operational/Managerial Control · Organization
Loveless, Kurt
5% Or Greater Indirect Ownership Interest · Individual
Loveless, Kurt
Operational/Managerial Control · Individual
Loveless, Kurt
Corporate Officer · Individual
Pittard, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Pittard, Jeffrey
Operational/Managerial Control · Individual
Salisbury Plain Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Spanish Fork Rehabilitation and Nursing
Spanish Fork, UT
1-star overall rating with 2-star inspections with abuse icon flag with $7,443 in total fines with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Provo Rehabilitation and Nursing
Provo, UT
3-star overall rating with 2-star inspections with abuse icon flag with $55,146 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#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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