Stonehenge of Cedar City
333 West 1425 North, Cedar City, UT 84721 · Iron County · 50 certified beds · avg 43 residents/day · certified since May 1, 2003
Part of chain: STONEHENGE OF UTAH (5 facilities, chain avg rating 4.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 · May 19, 2026 · F-0689 · triggered by a complaint
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: May 12, 2026 (Past Non-Compliance)
▲ Actual harm, one-off · Mar 26, 2026 · F-0550
The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Why it matters: Being treated without dignity harms a resident's self-worth, mental health, and overall quality of life.
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: May 18, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 26, 2026 · F-0725 · triggered by a complaint
The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Why it matters: Understaffing means longer waits for help, missed care, and higher risk of falls and other 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: May 18, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (19)
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 |
|---|---|---|
| May 19, 2026 | ▲ 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. · from a complaint |
| Mar 26, 2026 | ▲ G · Actual harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Mar 26, 2026 | ▲ G · Actual harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Mar 26, 2026 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Mar 26, 2026 | E · Potential for harm, repeated | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Mar 26, 2026 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. · from a complaint |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint |
| Mar 26, 2026 | D · Potential for 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. |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. · from a complaint |
| Feb 5, 2025 | 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. · from a complaint |
| Nov 30, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 1, 2021 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Dec 1, 2021 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Dec 1, 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. |
| Dec 1, 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. |
| Dec 1, 2021 | 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. |
| Dec 1, 2021 | D · Potential for 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. |
| Dec 1, 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. |
| Dec 1, 2021 | D · Potential for harm, one-off | The facility did not perform required COVID-19 testing on residents and staff. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (1 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 8 | 0 | F |
| 2023 | 1 | 0 | D |
| 2025 | 1 | 0 | D |
| 2026 | 9 | 3 | G ▲ |
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)
No fines or payment denials in the published 3-year window.
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) | 3.92 | 3.87 | 3.95 | top 29% in Utah; top 43% in the U.S. |
| Registered Nurse hours | 1.08 | 1.17 | 0.69 | top 42% in Utah; top 13% in the U.S. |
| Weekend total nurse staffing | 3.38 | 3.39 | 3.50 | top 29% in Utah; top 48% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.40 | 0.88 | 0.48 | bottom 7% in Utah; top 48% in the U.S. |
| Total nursing staff turnover (%) | 59.0 | 50.7 | 45.8 | bottom 30% in Utah; bottom 18% in the U.S. |
| RN turnover (%) | 42.9 | 40.6 | 42.9 | bottom 48% in Utah; bottom 49% 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 3.76, RN 1.04, weekend 3.25. Staffing rating: 4/5.
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: 4/5 · long-stay residents: 3/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Avebury Healthcare LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/01/2025 |
| Avebury Healthcare LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/05/2026 |
| 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 | Corporate Officer | NOT APPLICABLE | 12/20/1992 |
| 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 | 04/30/2026 |
| Loveless, Kurt | Individual | Corporate Officer | NOT APPLICABLE | 10/25/2021 |
| Loveless, Kurt | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/25/2021 |
| Loveless, Kurt | Individual | ADP of the SNF | NOT APPLICABLE | 10/25/2021 |
| Newman, Steven | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/19/2019 |
| Newman, Steven | Individual | ADP of the SNF | NOT APPLICABLE | 08/19/2019 |
| Stemmons, Kent | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/25/2021 |
| Stemmons, Kent | Individual | ADP of the SNF | NOT APPLICABLE | 10/25/2021 |
| Stonehenge of Cedar Cityut INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 10/25/2021 |
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?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "How do you help residents maintain their daily living skills, and how do you measure whether it's working?"
- "How do you handle residents who need modified food textures, and how do you make those meals appetizing?"
- "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 |
|---|---|---|---|---|---|
| Cedar Health and Rehabilitation | 0.1 mi | Cedar City, UT | ★★☆☆☆ | 2/5 |
Compare this facility with the 1 closest →
All facilities in Cedar City →
Facility data as of CMS processing date 2026-08-01. CCN 465153.