Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonehenge Of American Fork during CMS and state inspections, most recent first.
Unsafe food handling and poor personal hygiene were observed during meal service. The cook and a kitchen aide wore hairnets incorrectly, the dietary manager entered the food prep area without a hairnet, and a cell phone was present near the plate warmers. Staff also touched plate faces and food with dirty gloves, returned tongs and a spoon to food after contact with dirty gloves or other surfaces, and used a dirty rag to wipe food off a plate served to a resident.
A resident with CHF, morbid obesity, MDD, weakness, an above-knee amputation, and HTN reported that nighttime and daytime meds were often given too late and that she did not want to be awakened for bedtime meds. MAR review showed multiple late doses of gabapentin, plus late administration of a lidocaine patch and trazodone at bedtime; one gabapentin dose was also given only 3 hours after a prior dose. RN, SUM, and DON stated meds should be given within the ordered time frame and that the provider should be contacted if doses would be late or too close together.
Failure to provide SNF ABN for Medicare non-covered services. A resident did not receive a SNF ABN when Medicare Part A skilled services were ending and continued services might not have been covered. The SSD said the notice was discussed by phone with the resident's daughter due to the resident's cognition, but it was not documented.
A resident with dementia, weakness, HTN, limited mobility, and pressure ulcer risk had a care plan that included floating heels in bed, but was observed lying in bed with heels not floated. A weekly skin check identified a left heel wound, and later assessment found blanchable redness on the heel. The RN stated he had not been notified of the heel wound, and staff gave inconsistent understanding of the heel-floating requirement.
A resident with dementia, weakness, and limited mobility had an order and care plan intervention to float heels in bed for skin protection, and a weekly skin check documented a left heel wound. The resident was observed twice lying in bed with the heels not floated, and RN assessment later found blanchable redness on the left heel. RN stated staff were supposed to notify him of wounds and that residents with low mobility should have heels floated when in bed; the DON stated weekly head-to-toe assessments should identify and report wounds.
Unsafe Food Handling and Poor Personal Hygiene in Dietary Area
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards during lunch service. At 12:03 PM, the cook was observed wearing a hat with a hairnet over the top of it, but the hairnet was not covering her hair and her hair had fallen out of the hat. At 12:05 PM, a kitchen aide with her hair clipped up in the back was observed with a hairnet that covered only the hair in the clip and not the hair on her scalp. At 12:08 PM, the dietary manager entered the cooking area without a hairnet in place, and at 12:11 PM a cell phone was observed in the cooking area near the plate warmers. Additional unsafe food handling was observed during the same meal service. At 12:07 PM, the cook touched the face of plates with gloved hands that had touched her face and hair. At 12:12 PM, tongs used in the cheese container were laid on the counter and then placed back into the shredded cheese container. At 12:16 PM, the cook touched food on a plate with dirty gloves. At 12:19 PM, the spoon used to serve parmesan cheese was touched by dirty gloves and then fell back into the cheese. At 12:27 PM, a rag that had been used to wipe the counter and open the oven door was used to wipe excessive food off a plate that was given to a resident. The dietary manager stated that staff should have hair coverings that cover all hair, should not have cell phones in the food area, should not wipe plate faces with a dirty rag or touch them with dirty gloves, and that utensils should not touch dirty gloves or other surfaces and then be placed back into food for use.
Delayed Medication Administration
Penalty
Summary
The facility did not ensure that a resident had the right to make choices about significant aspects of life in the facility, specifically timely medication administration. Resident 18 was admitted with diagnoses including chronic diastolic congestive heart failure, morbid obesity, major depressive disorder, weakness, acquired absence of the left leg above the knee, and essential hypertension. During an interview, the resident stated that nighttime medications were often given too late, sometimes close to or after midnight, and that medications were also bothersome when given during the day. The resident stated she did not want to be woken up for medications that were supposed to be given before bedtime and believed medications should be given on time. Review of the June and July 2025 MAR showed multiple late administrations of gabapentin 300 mg ordered three times daily, including doses given several hours after the scheduled time and one instance where a dose was given at 11:00 AM and again at 2:43 PM, only three hours apart. The MAR also showed lidocaine 4% patch and trazodone 50 mg at bedtime were both given at 11:04 PM instead of 7:00 PM on one occasion. RN 2 stated medications due at 7:00 AM could be given between 6:00 and 8:00 AM and that if a medication was not administered within the appropriate time frame, the doctor should be contacted. The SUM stated staff could administer medications at the due time or within an hour, and if administration would go past the due time, the doctor should be contacted. The DON stated staff had a flex time for medication administration, but expected providers to be notified if medications were to be given late and stated it was not appropriate to give gabapentin too close together.
Failure to Provide SNF ABN for Medicare Non-Covered Services
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on interview and record review, the facility failed to inform each resident periodically during the resident's stay of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. For one sampled resident, resident 14, a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) was not provided when the beneficiary intended to continue services that might not have been covered under Medicare. A SNF Beneficiary Notification Review completed by the Social Services Director indicated the resident's Medicare Part A skilled services episode began on 01/31/25, the last covered day of Part A service was 04/19/25, and the facility/provider initiated discharge from Medicare Part A services when benefit days were not exhausted. The review also indicated that a SNF ABN was not provided to the resident and was discussed with the daughter by phone due to the resident's cognition. During interview, the Social Services Director stated the SNF ABN was discussed with the resident's daughter, who was the resident representative, but it was not documented because it was done over the phone, and stated the daughter came into the facility often and should have received the SNF ABN.
Failure to Implement Heel-Floating Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for a resident whose comprehensive assessment identified medical, nursing, and skin integrity needs. The resident was admitted with diagnoses including second degree atrioventricular block, dementia, weakness, and hypertension, and assessments showed the resident required staff assistance for bed mobility, transfers, and walking, was totally dependent on staff for locomotion, and was at risk for pressure ulcers. A weekly skin check also identified a left heel wound, and the care plan included interventions such as turning and repositioning every two hours and floating heels when in bed. During observation, the resident was seen lying in bed on his back with his heels not floated, despite the care plan intervention requiring heel floating. When the resident’s heels were later assessed, blanchable redness was observed on the left heel, and the RN stated he had not been aware of a heel wound and that staff were supposed to notify him if a wound was identified. A CNA stated the resident had to have his heels floated and that she had been floating them on previous shifts, while another CNA stated the resident had to have his heels floated but did not know why. The RN stated that if a resident had low mobility, staff were supposed to float the heels when the resident was in bed and that care plan updates were expected to be communicated to CNAs through the Kardex and by nurses.
Failure to Float Heels for Resident With Blanchable Heel Redness
Penalty
Summary
The facility failed to ensure that a resident with impaired skin integrity received ordered heel protection and care consistent with the resident’s condition. Resident 88 was admitted with diagnoses including second degree atrioventricular block, dementia, weakness, and hypertension, and the admission assessments showed the resident required staff assistance for bed mobility, transfers, and walking, was totally dependent on staff for locomotion, and was at risk for developing a pressure ulcer. The care plan included interventions to float heels when in bed, and a physician order dated 7/9/25 directed staff to float heels for protection of skin integrity. On 7/22/25, the resident was observed lying in bed with the heels not floated. The medical record showed a weekly skin check on 7/11/25 documenting a left heel wound, and later that day RN 1 assessed the left heel and found blanchable redness. RN 1 stated he had not been aware of a wound on the heel, told CNA 1 to float the heels, and indicated he would enter an order for heel floating and skin prep. On 7/23/25, the resident was again observed lying in bed with the heels not floated. During interview, RN 1 stated staff were supposed to notify him if a wound was identified and that residents with low mobility should have their heels floated when in bed; the DON stated weekly head-to-toe assessments were supposed to be completed and any wound reported to RN 1 and the house physician.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near American Fork
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Monument Healthcare American Fork | 1.1 mi | ★★★★★ | 7 | 0 |
| Mission At Alpine Rehabilitation Center | 2.7 mi | ★★★★★ | 34 | 5 |
| Stonehenge Of Orem | 6.4 mi | ★★★★★ | 1 | 0 |
| Cascades At Orchard Park | 6.5 mi | ★★★★★ | 0 | 0 |
| Pointe Meadows Health And Rehabilitation | 6.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.