Stonehenge of American Fork

Name: Stonehenge of American Fork
Address: 538 South 500 East, American Fork, UT, 84003, US
Telephone: 8016422000

538 South 500 East, American Fork, UT 84003 · Utah County · 119 certified beds · avg 90 residents/day · certified since Sep 21, 2012

Part of chain: STONEHENGE OF UTAH (5 facilities, chain avg rating 4.0★)

4/5

Health inspection rating (on-site)

Serious findings on record

$21,590

Fines, last 3 years

3.70

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Oct 10, 2023 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 30, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Nov 18, 2021 · F-0684

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jan 7, 2022 (Deficient, Provider has date of correction)

All citations in the current public record (16)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jul 23, 2025	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jul 23, 2025	D · Potential for harm, one-off	The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time.
Jul 23, 2025	D · Potential for harm, one-off	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Jul 23, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jul 23, 2025	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Oct 10, 2023	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Oct 10, 2023	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Oct 10, 2023	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Nov 18, 2021	▲ G · Actual harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Nov 18, 2021	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 18, 2021	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Nov 18, 2021	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Nov 18, 2021	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Nov 18, 2021	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Nov 18, 2021	D · Potential for harm, one-off	The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them.
Nov 18, 2021	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (3 → 5).

Year	Citations	Serious (G–L)	Worst severity that year
2021	8	1	G ▲
2023	3	1	G ▲
2025	5	0	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $21,590.

Date	Type	Amount / length
Oct 10, 2023	Fine	$21,590

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Utah avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.70	3.87	3.95	top 38% in Utah; bottom 47% in the U.S.
Registered Nurse hours	1.00	1.17	0.69	top 47% in Utah; top 16% in the U.S.
Weekend total nurse staffing	3.18	3.39	3.50	top 42% in Utah; bottom 41% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.90	0.88	0.48	top 37% in Utah; top 8% in the U.S.
Total nursing staff turnover (%)	62.0	50.7	45.8	bottom 23% in Utah; bottom 14% in the U.S.
RN turnover (%)	61.8	40.6	42.9	bottom 14% in Utah; bottom 19% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.94, RN 1.07, weekend 3.39. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Carrera, Rory	Individual	Operational/Managerial Control	NOT APPLICABLE	12/15/2022
Carrera, Rory	Individual	ADP of the SNF	NOT APPLICABLE	12/15/2022
Cursus Healthcare LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	11/01/2025
Cursus Healthcare LLC	Organization	ADP of the SNF	NOT APPLICABLE	12/31/2025
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	11/01/2025
Gillespie, Deborah	Individual	Operational/Managerial Control	NOT APPLICABLE	10/25/2021
Gillespie, Deborah	Individual	ADP of the SNF	NOT APPLICABLE	10/25/2021
Howells, Stephen	Individual	Operational/Managerial Control	NOT APPLICABLE	10/25/2021
Howells, Stephen	Individual	ADP of the SNF	NOT APPLICABLE	10/25/2021
Kane County Human Resource Special Service District	Organization	Operational/Managerial Control	NOT APPLICABLE	10/25/2021
Kane County Human Resource Special Service District	Organization	ADP of the SNF	NOT APPLICABLE	09/09/2025
Loveless, Kurt	Individual	Operational/Managerial Control	NOT APPLICABLE	10/25/2021
Loveless, Kurt	Individual	ADP of the SNF	NOT APPLICABLE	10/25/2021
Wood, Zachary	Individual	Operational/Managerial Control	NOT APPLICABLE	11/01/2025
Wood, Zachary	Individual	ADP of the SNF	NOT APPLICABLE	11/01/2025

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
"Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Monument Healthcare American Fork	1.1 mi	American Fork, UT	★★★☆☆	2/5
Mission at Alpine Rehabilitation Center	2.7 mi	Pleasant Grove, UT	★★☆☆☆	1/5	abuseSFF
Stonehenge of Orem	6.4 mi	Orem, UT	★★★★★	5/5
Cascades at Orchard Park	6.5 mi	Orem, UT	★★★★☆	4/5
Pointe Meadows Health and Rehabilitation	6.8 mi	Lehi, UT	★★★★★	4/5
Orem Rehabilitation and Nursing Center	8.8 mi	Orem, UT	★★★☆☆	2/5
Aspen Ridge of Utah Valley	9.3 mi	Orem, UT	★★★★★	5/5
Provo Rehabilitation and Nursing	10.4 mi	Provo, UT	★☆☆☆☆	1/5	abuseSFF
Draper Rehabilitation and Care Center	11.3 mi	Draper, UT	★★★★☆	4/5
Neurorestorative	12.2 mi	Riverton, UT	★★★★☆	3/5
Rocky Mountain Care - Riverton	14.3 mi	Riverton, UT	★★★★☆	3/5
Stonehenge of South Jordan	15.4 mi	South Jordan, UT	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in American Fork →

Facility data as of CMS processing date 2026-08-01. CCN 465178.

The Care File

Visit checklist — Stonehenge of American Fork

538 South 500 East, American Fork, UT 84003 · 8016422000

Health inspection rating 4/5 · CMS overall 4/5· Fines (3y): $21,590

Most serious findings on record:

▲ Oct 10, 2023 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ Nov 18, 2021 (F-0684, Actual harm, one-off): The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
☐ "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 465178 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)