Stonehenge of Richfield

In the surveyor’s words

From the most serious findings on record at Stonehenge of Richfield, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 2, 2021

  Based on interview and record review it was determined, for 1 of 17 sampled residents, that the facility did not ensure that the resident environment remained as free of accident hazards as was possible. Specifically, a resident that required two staff members assistance sustained a fall resulting in 6 sutures to her face when one staff member was assisting her. These findings were cited at a harm level. Resident identifier 4. Findings included: HARM Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure, [CONDITION(S)], history of falling, [CONDITION(S)], and peripheral [CONDITION(S)]. On 8/31/21 resident 4's medical record was reviewed. […]

• No harm, potential for more than minimal, widespreadF801Sep 2, 2021

  Based on interview and record review, it was determined that the facility did not employ a clinically qualified full-time dietitian or other clinically qualified nutrition professional to serve as the Director of Food and Nutrition Services. Specifically, the facility did not employ a full-time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the Director of Food and Nutrition Services. Findings included: On 8/30/21 at 12:33 PM, a tour of the facility kitchen was conducted. At that time the facility DM was interviewed. The DM stated, I don't have my CDM (Certified Dietary Manager). The DM stated she was currently enrolled in a CDM program. […]

• No harm, potential for more than minimal, patternF605May 29, 2025

  Based on interview and record review, for 3 of 15 sampled residents, the facility did not ensure that residents who used psychotropic drugs received a gradual dose reduction, and behavioral interventions unless clinically contraindicated in an effort to discontinue the drugs; additionally the facility did not ensure PRN (as needed) orders for psychotropic drugs were limited to 14 days unless clinically contraindicated. Specifically, there was no rationale after 90 days for continued use of a prn anti-anxiety medication, another resident did not have a rationale for continuation of an anti-depressant and anti-anxiety and another resident did not have a gradual dose reduction that was ordered by the physician implemented. Resident identifiers: 2, 7 and 11. Findings included: 1. […]

• No harm, potential for more than minimal, patternF801May 29, 2025

  Based on interview, the facility did not employ a full time Director of Food and Nutrition Services with the required qualifications of Certified Dietary Manager, Certified Food Service Manager or with a degree in food service management or 2 or more years of experience as a director of food and nutrition services. Specifically, the facility's Certified Dietary Manager was employed part time and the full-time Dietary Manager was not yet certified to work as a Dietary Manager. Findings included: On 5/27/25 at 12:42 PM an interview was conducted with the Dietary Manager in Training (DMT) who stated she was the full-time manager but was not certified. The DMT stated she was preparing to take the courses necessary to be certified. […]

• No harm, potential for more than minimal, patternF812May 29, 2025

  Based on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer, walk-in refrigerator and dry food storage room were open to the air. Additionally, food items in the food storage room were past their use by dates. Findings included: On 5/27/25, at 12:42 PM, an initial walk-through of the kitchen was conducted. In the walk-in freezer, a box of bulk frozen peas was open to air. In the dry food storage room, a box of dried mashed potatoes was open to air, a box of baking soda was open to air. A bottle of apple cider vinegar with an open date of 11/13/23 had a use by date of 12/20/24. […]