Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonehenge Of Richfield during CMS and state inspections, most recent first.
Three residents did not receive appropriate management of psychotropic medications, including lack of gradual dose reduction, missing physician rationale for continued PRN anti-anxiety medication, and failure to implement a recommended dose reduction for an antidepressant. Documentation gaps and confusion over medication orders contributed to the deficiencies, as confirmed by staff interviews and record review.
The facility did not employ a full-time, qualified Director of Food and Nutrition Services, as the full-time Dietary Manager in Training was not certified and the certified Dietary Manager worked only part-time, with oversight from a Corporate Dietitian who visited quarterly.
Surveyors found that multiple food items in the kitchen, including frozen and dry goods, were left open to air and several items were past their use by or best used by dates. Despite regular audits and ongoing staff education, the facility did not maintain proper food storage practices, leading to deficiencies in food service safety standards.
Staff failed to follow infection control protocols during meal and medication passes, including delivering uncovered food and beverages to residents and a nurse placing her bare thumb inside medication cups before administering medications. Both dietary and nursing staff acknowledged these practices were not sanitary.
A resident with a history of joint replacement surgery was discharged AMA, but the facility did not notify the LTC Ombudsman as required. Interviews with the RA, BOM, and DON revealed inconsistent understanding and practice regarding Ombudsman notification, with staff only notifying in select cases rather than for all discharges.
Two residents receiving oxygen therapy were inaccurately documented in their MDS assessments as not using oxygen, despite physician orders, care plans, and staff interviews confirming regular oxygen use. The MDS Coordinator acknowledged the error after reviewing the records and discussing with surveyors.
A resident with neurological and respiratory conditions did not have a comprehensive care plan addressing oral hygiene, despite requiring setup or cleanup assistance. Staff provided reminders and occasional help, but there was no specific care plan with measurable objectives or timeframes for oral care, and communication between shifts about oral hygiene completion was lacking.
A resident with neurological and respiratory conditions was found with significant buildup on his teeth, despite requiring setup or cleanup assistance for oral hygiene. Staff provided reminders and occasional assistance, but there was no consistent documentation or communication between shifts to ensure oral care was completed, resulting in inadequate support for the resident's ADL needs.
Failure to Ensure Proper Psychotropic Medication Management and Documentation
Penalty
Summary
The facility failed to ensure appropriate management of psychotropic medications for three residents, specifically regarding gradual dose reduction (GDR), behavioral interventions, and proper documentation for continued use of PRN (as needed) medications. For one resident with severe cognitive impairment and a history of depression and anxiety, the facility continued PRN Ativan orders beyond the initial 90-day period without documented physician rationale for its ongoing use. The medication was administered multiple times over several months, and staff interviews confirmed the absence of required documentation supporting the continued PRN order. Another resident with diagnoses including dysthymic disorder and anxiety was maintained on two antidepressant medications, Citalopram and Bupropion, with dose adjustments over time. However, the medical record lacked documentation of a physician's response to a rationale for duplicative therapy and did not include evidence of a second GDR or justification for not reducing the medications further, as required by regulations. The DON acknowledged confusion regarding the medication orders and confirmed the absence of necessary documentation for dose reduction or rationale. A third resident with neurological and respiratory conditions was prescribed Trazodone for insomnia. Although a GDR was recommended and discussed in a psychotropic review meeting, the order to reduce the dose was not correctly implemented in the medical record. The DON admitted to documenting the recommendation in a progress note but failing to update the physician order for signature, resulting in the GDR not being carried out as intended.
Lack of Qualified Full-Time Dietary Manager
Penalty
Summary
The facility failed to employ a full-time Director of Food and Nutrition Services with the required qualifications, as mandated by regulations. The full-time Dietary Manager in Training (DMT) was not certified and was in the process of preparing for certification, while the previous certified Dietary Manager (DM) was only working part-time, approximately 20 hours per week or less, and was available by phone. The DM was training the DMT to take the necessary courses for certification. Additionally, the Corporate Dietitian (CD) provided remote assessments and only visited the facility quarterly for one day to review resident charts, documentation, and conduct audits. These actions resulted in the facility not having a full-time, qualified individual overseeing the food and nutrition service as required.
Improper Food Storage and Expired Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During two separate walk-throughs of the kitchen, multiple food items in the walk-in freezer, walk-in refrigerator, and dry food storage room were found open to the air, including boxes of bulk frozen peas, omelet replacements, omelets, dried mashed potatoes, and baking soda. Additionally, several food items in the dry storage room were found to be past their use by or best used by dates, such as apple cider vinegar, baking powder, yeast, Worcestershire sauce, and Maltomeal. During an interview, the Dietary Manager confirmed that the Corporate Dietitian conducted quarterly kitchen audits, which included inspections of the refrigerator and dry storage areas. The findings from these audits were shared with the Dietary Manager, the Administrator, and the Director of Nursing, and were used to educate kitchen staff about sanitation and proper food storage. Despite ongoing education, the facility did not ensure that all food items were properly stored and within their use by dates, resulting in the observed deficiencies.
Failure to Maintain Infection Control During Meal and Medication Passes
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations during meal and medication passes. During several meal services, food and beverages such as lemonade, milk, juice, soup, and cold cereal were transported and delivered to residents while uncovered, exposing them to potential environmental contaminants. Additionally, a dietary aide was observed returning to a resident's room with uncovered drinks, and water condensate from a milk bottle was observed splashing into a resident's soup. These actions occurred repeatedly during both breakfast and lunch meal services in the resident hallways. During medication administration, a registered nurse was observed placing her bare thumb inside medication cups before placing medications in them and administering them to residents. This practice was repeated for multiple residents during the morning medication pass. Both the nurse and the Director of Nursing acknowledged during interviews that touching the inside of medication cups with bare hands is not sanitary and should not occur. These observations demonstrate a lack of adherence to basic infection control protocols during both meal and medication administration.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
A deficiency was identified when the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for one resident. The resident, who had been admitted with diagnoses including aftercare following joint replacement surgery and the presence of a right artificial knee joint, was discharged against medical advice (AMA) to home. Documentation in the nurse's note confirmed the discharge event. Interviews with facility staff revealed a lack of consistent practice and training regarding notification of the Ombudsman. The Resident Advocate (RA) and Business Office Manager (BOM) both stated that they did not notify the Ombudsman for every discharge, only in cases they considered difficult or when there were concerns for the resident's safety. The Director of Nursing (DON) was unaware that all discharges required notification, and the Regional Nurse Consultant (RNC) clarified that notification should occur for every discharge, typically via a monthly summary. This inconsistency led to the failure to notify the Ombudsman about the resident's discharge.
Inaccurate MDS Assessment of Oxygen Use
Penalty
Summary
Two residents with physician orders for oxygen therapy were not accurately assessed in their Minimum Data Set (MDS) documentation. Both residents had medical records, treatment administration records, and care plans indicating the use of oxygen, either at night or as needed, with specific instructions for oxygen administration and equipment maintenance. Despite this, their quarterly MDS assessments indicated that they were not using oxygen while in the facility. Interviews with staff, including a CNA and the DON, confirmed that both residents used oxygen at night and occasionally during the day. The MDS Coordinator, responsible for completing the assessments, acknowledged that the MDS entries for these residents were incorrect after reviewing the documentation and discussing the findings with the surveyor. The deficiency was identified through a combination of record review and staff interviews.
Failure to Develop and Implement Comprehensive Oral Hygiene Care Plan
Penalty
Summary
A deficiency was identified when a resident with neurological conditions, respiratory failure, and seizure disorder did not have a comprehensive, person-centered care plan addressing oral hygiene needs. The resident was observed with white buildup on his teeth and reported brushing his own teeth, but had not seen a dentist during his stay. The Minimum Data Set (MDS) assessment indicated the resident required setup or cleanup assistance with oral hygiene, yet the care plan only generally addressed assistance with activities of daily living (ADLs) and did not specifically include measurable objectives or timeframes for oral hygiene care. Certified Nursing Assistant (CNA) documentation showed the resident received oral care assistance only 8 times in 14 days, and there were no documented concerns about teeth or gums in the nursing progress notes. Interviews with staff revealed that reminders and encouragement were provided, but there was no consistent communication between shifts regarding whether the resident completed oral hygiene. The Director of Nursing confirmed that a care plan should have been developed to address the resident's need for more assistance with oral hygiene.
Failure to Ensure Consistent Oral Hygiene Assistance
Penalty
Summary
A deficiency was identified when a resident with neurological conditions, respiratory failure, and seizure disorder was observed to have white buildup on his teeth, indicating inadequate oral hygiene. The resident reported brushing his own teeth but had not seen a dentist either in or out of the facility. Review of the resident's medical record showed he required setup or cleanup assistance with oral hygiene, and the care plan directed staff to assist with activities of daily living (ADLs) as needed, encouraging independence and providing adaptive equipment if necessary. However, CNA documentation indicated that oral care assistance was only provided 8 times in the last 14 days, and there were no nursing notes documenting concerns with the resident's oral health during the review period. Interviews with staff revealed that reminders to brush teeth were given, but there was no consistent follow-up or communication between shifts to ensure the resident completed oral hygiene. The CNA stated that the resident often postponed brushing his teeth and that it was not routinely communicated between shifts whether he had completed this task. The DON was unaware of where oral hygiene was documented and did not know if reminders were passed along during shift changes. These actions and inactions led to the resident not receiving appropriate treatment and services to maintain or improve his ability to carry out ADLs, specifically oral hygiene.
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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 Richfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission At Richfield Nursing And Rehabilitation | 0.4 mi | — | 0 | 0 |
| Mission At Community Living Rehabilitation Center | 27.5 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 August 2026) and official state health department websites.