Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on observation and interview, the facility failed to provide dining experience in a manner that
maintains or enhances each resident's dignity for 41 of 41 residents (R2- R9, R13-R17, R19, R22, R24,
R26-R28 ,R30, R33, R34, R36, R38-R40, R42-R45, R47-R50, R52, R55 ,R56 R58, R59, R110, R211)
reviewed for dining in a sample of 55.
On 10/16/2022 at 11:45am, residents were observed gathered in the dining room for the noon meal. On
10/16/2022 at 10:30am, V1 (Administrator) said the facility starts serving the residents their noon meal at
12:00pm.
1. On 10/16/2022 at 12:42pm, the first tray was observed being sent out of the kitchen to be served to a
resident on the hall. R17 was quietly seated in the dining room, at the same table as R30 and R56. At
12:45, V56 received her tray while R17 and R30 remained waiting for their meal to be served. At 12:55pm,
R17 began shouting I ' m hungry, can I have something to eat? and Please give me something to eat. and
continued to cry out for her meal until she was served at 1:12pm. R56 was observed offering some of her
food to R17 in an attempt to calm R17 down. At the table next to R17, R3 was served his meal at 12:42pm,
while R45 and R59 continued to wait. At 12:59, R59 received his tray while R45 continued to wait to be
served. R59 and R3 finished their meal and left the table before R45 was served at 1:10pm. While waiting
R45 began to yell at staff to inquire about where his food tray was and that he had been forgotten, but staff
would not stop to assist him with his question.
2. On 10/16/2022 at 1:22pm, R9 was observed wandering about the dining room in her wheelchair. R9 was
observed eating food from the other resident's plates who had finished and left the dining room. V11
(Certified Nursing Assistant/CNA) also observed R9's activities. V11 was asked if R9 had been served yet
and V11 did not know. V12 (Dietary Aide) said R9 had not been served yet. V12 was told about R9 eating
off other residents plates due to be hungry and how much longer until R9's tray was served. V12 replied R9
does that all the time and her behavior was typical. Before being served her own meal tray, R9 was
observed finishing a half eaten chicken salad sandwich which had first been served to R19. R9 had
dropped a large chunk of sandwich onto the floor. R9 was observed picking the sandwich off the floor and
eating it. V11 was observed watching R9 along with the surveyor. V11 was asked about R9 eating off the
floor, but V11 did not attempt to stop R9 nor attempt to redirect R9 in any way. V11 would only answer (R9)
had not been served her meal yet.
3. On 10/16/2022 at 1:06pm, R49 was observed sitting with two of her family members. All three were
waiting to be served. R49 and her guests patiently waited to be served while all other members of the table
were served, had eaten and left the table. R49 and her guests were finally served at 1:26pm.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
146144
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146144
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonebridge Nursing & Rehab
902 South McLeansboro
Benton, IL 62812
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
4. On 10/16/22 at 12:25 PM, V12 (Dietary) stated, we are going to have to use disposable bowls and small
bowls for the desserts because we do not have enough of the regular ones.
On 10/16/22 between 12:25 PM to 1:50 PM the side salad, the diced tomato salad, and the sliced
cucumbers were served in disposable bowls and the pear cobbler and the sliced pears were served in
disposable small bowls to R2, R3, R4, R5, R6, R7, R8, R9, R13, R14, R15, R16, R17, R19, R22, R24, R26,
R27, R28, R30, R33, R34, R36, R38, R39, R40, R42, R43, R44, R45, R47, R48, R49, R50, R52, R55,
R56, R58, R59, R110, and R211.
On 10/16/22 at 1:10 PM, V12 (Dietary) stated, We need some disposable spoons and knives, I don't have
any left for the rest of the trays and four residents were served with plastic ware before they stopped
serving lunch and washed some spoons so that non disposable spoons could be used.
On 10/16/22 between 1:10 PM and 1:15 PM R38, R52, R43 and R5 were given disposable spoons and
knives.
On 10/17/22 between 12:00 PM and 1:15 PM, the creamed corn and the tropical fruit were served in
disposable bowls to R2, R3, R4, R5, R6, R7, R8, R9, R13, R14, R15, R16, R17, R19, R22, R24, R26, R27,
R28, R30, R33, R34, R36, R38, R39, R40, R42, R43, R44, R45, R47, R48, R49, R50, R52, R55 ,R56 R58,
R59, R110, and R211.
On 10/19/22 at 1:00 PM, R38 received her whole lunch on disposable ware.
On 10/19/22 at 1:45 PM, V27 (Dietary) stated, R38 was served on disposable ware due to we did not have
any regular dishware left. Small disposable bowls are used for desserts due to not having enough bowls to
serve with and large disposable bowls are used sometimes because we don't have enough bowls to use
either. Sometimes we do run out of regular silverware and have to use disposable.
On 10/17/22 at 12:30 PM, R13 was sitting at a table with two other residents that were eating, he did not
have his lunch yet and was heard repeating, please come to me, at 12:50 PM R13 wanted to go back to his
room and was observed waving his arm towards any staff that came by him. At 12:59 PM, R13 received his
lunch, the other two residents at his table had already finished their lunch and left the table.
5. On 10/17/22 at 12:20 PM, V22 (Laundry Aide) pushed a soiled linen cart through the middle of the dining
room while residents were being served their noon meal. Soiled linen was stacked up approximately three
feet above the lid of the soiled linen cart and a sheet was covering it. V22 had her hand raised above her
head and resting on the sheet covering the pile of soiled linen while she pushed the soiled linen cart.
Residents were being served lunch at the time the soiled linen cart was being pushed through the dining
room. Multiple residents were seated at tables in the dining room while the cart was pushed through the
dining room and about half of the residents were eating their meal.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146144
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146144
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonebridge Nursing & Rehab
902 South McLeansboro
Benton, IL 62812
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed assistance with bathing for to 12 of 17 residents
(R8, R18, R29, R31, R32, R36, R41, R49, R50, R51, R54, R57) reviewed for dependent care in a sample
of 55.
Residents Affected - Some
Findings included:
On 10/17/2022 at 9:30am, V1 (Administrator) presented a facility document titled Resident Census and
Condition. This document showed the facility has a census of 61 residents and of the 61 residents 59 of
them require assistance of one or two staff for transferring and 42 residents require the assistance of 1 or 2
staff for personal hygiene needs.
1. On 10/18/2022, the shower schedule for the the evening shift of 10/17/2022 was reviewed with V6
(Corporate Administrator). R41, R18, R36, R50, R26, R44, R49, R7 and R8 were all scheduled to receive
their showers per this schedule. V6 was asked to provide documentation of who received their scheduled
shower on the evening of 10/17/2022. V6 provided a document titled Complete Care Details a summary
lookback for 10/17/2022 for all units which listed the resident's who were bathed that day. This list
documented 4 residents (R24 (not scheduled), R26, R44 and R7) received showers. This list showed R41,
R18, R36, R50, R49 and R8 did not receive their showers as scheduled. V6 said she did not know why all
the residents who were scheduled did not get showered.
On 10/20/2022 at 11:00am, V32 (CNA/Certified Nursing Assistant) said she worked the evening shift on
10/17/2022 and she gave showers to R44, R24 and R26, which she documented. V32 said she was not
sure if any other showers were given that evening.
2. On 10/18/2022 at 9:00am, R36 said she was scheduled to get a shower on the evening of 10/17/2022
and she wanted her shower, but no one came to give her one. R36 said she misses a lot of showers
because there is not enough staff to give her one. R36 said she needs extensive assistance for all personal
hygiene tasks. On 10/19/2022 at 10:00am, R36 said she still had not received a shower and it had been
over a week since she was last showered. R36's medical records under MDS (Minimum Data Set) dated
9/11/2022 documents R36's BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating R36 is
cognitively intact and under section G of the MDS it documented R36 needs physical help in part for
bathing.
3. On 10/18/2022 at 12:15pm, R41 and R32 both alert to person, place and time were together in their
room. Both said R41 was scheduled to get a shower the evening before (10/17/2022) but no one ever came
and offered him to take a shower. Both said they are lucky to get even one shower a week and frequently
don't get that because the facility is short of staff. R41's medical record under MDS under section G and
dated 9/23/2022 documented R41 did not have the bathing activity occur or was provided by family 100 %
in the previous 7 days. R32's most recent MDS documents R32 needs supervision with bathing.
4. On 10/18/2022 at 12:30pm, R57 said the facility does not have enough staff. R57 said he and others do
not get showers when scheduled and they have to beg to get showered. R57 said this issue has been
brought up several times in resident council meetings but nothing is ever done about it. R57's medical
records under MDS section C and G and dated 10/7/2022 documented R57 has a BIMS of 14 indicating
R57 is cognitively intact and requires total assistance with bathing.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146144
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146144
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonebridge Nursing & Rehab
902 South McLeansboro
Benton, IL 62812
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
5. On 10/18/2022 at 12:38pm, R54 said she does not get her scheduled showers and sometimes doesn't
even get showered once per week. R54 said the facility needs more staff. R54's medical record under MDS
section C and G, dated 10/05/2022 documents R54 has a BIMS of 14 indicating R54 is cognitively intact
and needs physical help in part with bathing.
6. On 10/18/2022 at 12:42pm, R51 said the facility does not have enough staff to give showers and provide
proper care to the residents. R51 said she does not get her scheduled showers and often does not get
showered once per week. R51's medical record under MDS sections C and G and dated 10/12/2022
documented R51 has a BIMS of 15 indicating R51 is cognitively intact and requires total dependence with
bathing.
7. On 10/17/2022 at 9:30am, R31 said there used to be 2 CNAs (Certified Nursing Assistants) assigned to
work her hall on dayshift and on evening shift but for several weeks now there has only been one assigned.
R31 stated she only gets a shower if she asks the staff for one otherwise she does not receive them. R31's
medical records under tab titled MDS section C and G dated 9/16/2022 documented R31 has BIMS of 15
indicating R31 is cognitively intact and needs
physical help in part with bathing.
8. On 10/17/22 at 10:33 AM, R29 stated that there is usually 2 CNAs working on her hall and lately there
has only been 1 CNA working her hall. R29 stated that she needs 2 CNAs to get her out of bed. R29 stated
she transfers using a patient lifting machine which takes 2 people to use and she must wait for another staff
member to be found before she can be transferred or showered. R29's medical records under tab MDS
sections C and G dated 8/31/2022 documented R29 has a BIMS of 15 indicating R29 is cognitively intact
and needs extensive assistance of 2+ staff for transferring and is listed as total dependence of staff for
bathing.
On 10/18/2022 at 10:36am, V16 (Registered Nurse) said the facility is short staffed on all shifts especially
CNAs (Certified Nursing Assistants). V16 said the residents in this facility are very elderly and need more
assistance than a younger population would need. V16 said their skin is more fragile so staff cannot be
rushed when caring for them because they can be injured more easily.
On 10/18/2022 at 10:39am, V15, V17 and V18 (Certified Nursing Assistants) all said the facility is very short
of staff and it is hard to complete all showers scheduled. V17 said she's worked at this facility for 2-3 years
and she has always felt 3 care staff on the evening shift is not enough staff to provide all the care the
residents need. V17 said it didn't used to be like that but has been for several months now. V15, V17 and
V18 all said they can not complete the scheduled showers due to not having enough time or not enough
staff, but they are doing the best they can.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146144
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146144
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonebridge Nursing & Rehab
902 South McLeansboro
Benton, IL 62812
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to lock the wheels on a resident's bed and failed to provide
the required level of assistance with bed mobility for 1 of 8 residents (R55) reviewed for falls in the sample
of 55. This failure resulted in R55 falling out of bed, suffering a fractured left femur, and subsequently being
admitted to the hospital for surgical intervention.
Findings Include:
R55's facility document titled, Face Sheet documents R55 was admitted to the facility on [DATE] with an
admitting diagnosis of heart failure, muscle weakness, polyneuropathy, and type 2 diabetes mellitus. R55's
Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status (BIMS) score of 15,
indicating R55 is cognitively intact. This same MDS documents R55's Functional Status as requiring
extensive assistance x 2 person physical assist with bed mobility.
On 10/17/2022, at 8:50 a.m., R55 stated that on 6/27/2022, V23 (Registered Nurse/RN) came into her
room to do her treatment on her bottom. R55 stated that V23 assisted in rolling her on her right side toward
the wall. R55 stated she and V23 were the only ones in the room. R55 stated V23 turned away from her to
get her treatment supplies and at that time, R55 stated the bed started to move away from the wall and
before she could tell V23, she had fallen out of the bed onto the floor face-first between the wall and the
bed. R55 stated that she started to have severe pain in her left leg and hit her head on the floor. R55 stated
that V23 ran out of the room and V7 (Licensed Practical Nurse/LPN) came back into the room and looked
her over. R55 stated she was sent out to the hospital and was told she had a broken leg and said she had a
golf ball size bruise to the middle of her forehead. R55 stated that she had surgery on her left leg. R55
stated that at that time before she had her fall, she had one bed rail (1/2) on the upper left side of the bed.
R55 stated she did not know why V23 rolled her to the other side that did not have a bed rail to hold onto.
On 10/20/2022, at 10:00 a.m., V7 (LPN) stated that on 6/27/2022, 12:00 p.m., she was standing by the
bathroom door outside of R55's room and heard a loud bang and then saw V23 (RN) come out of the room.
V7 stated that she and V23 entered R55's room and rotated her onto her back and waited for the
ambulance to arrive. V7 stated that there were no other people in the room when she entered to help V23
with R55. V7 stated that R55 was located between the bed and the wall when she and V23 repositioned
R55 on her back.
R55's medical records documents on 6/27/2022, at 4:20 p.m., local hospital history and physical, under
section, Patient's Chief Complaint: Fall .Patient presented to local hospital emergency department due to
fall. She states she has chronic wounds on her sacrum in dependent areas for which she was attempting to
get wound care today. She states that she was rolled over and that the bed was not locked and slid away
from the wall causing her to fall between the bed and the wall. Further x-rays and computed tomography
(CT) revealed left distal femur comminuted fracture. Ortho was consulted and she will be admitted for
further workup and treatment. Signed by V24 (local physician).
R55's medical records, titled After Visit Summary dated 6/29/2022, under section, Surgical/Procedural
Cases on This Admission, Open Reduction and Internal Fixation (ORIF), fracture, femur using
intramedullary implant and interlocking screw by V26 (local surgeon). R55 returned back to the facility on
7/06/2022.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146144
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146144
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonebridge Nursing & Rehab
902 South McLeansboro
Benton, IL 62812
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Actual harm
Residents Affected - Few
R55's facility document titled, Resident Incident Report dated 6/27/2022, documents Resident side lying on
right side during treatment. Bed raised approximately 3 feet, bed locked on bottom, checked with R55 to
see if she was ok lying on her side. V23 (RN) turned around to get treatment supplies and R55 rolled out of
the side of the bed landing on her stomach. R55 reported she hit her left leg and her head. R55 had a golf
ball sized raised area on her head in the front middle area and reported pain in her left leg. Order obtained
for transport to hospital to evaluate and treat. R55's facility document titled, Incident Investigation dated
6/27/2022, documents Full Investigation has been completed on this investigation. It was found that R55
was lying in bed and V23 (Registered Nurse) entered the room to do R55's treatment. R55 is independent
with bed mobility and went to roll over so V23 could complete treatment and rolled off the side of the bed
onto the floor. Interdisciplinary team (IDT) determined the root cause of this incident is R55's poor bed
mobility and poor safety awareness. By V6, (Regional Administrator).
On 10/18/2022 at 11:25 a.m., V20 (Director of Therapy) stated that R55 was evaluated for physical therapy
on 7/19/2022 and R55's previous level of functioning was maximum assistance x 2 with rolling left to right
with bed mobility.
On 10/18/2022 at 1:55 p.m., V21 (Minimum Data Set/MDS Coordinator) stated that extensive assistance is
2 person physical assistance with bed mobility, transfer, walking, dressing, eating, toileting, and personal
hygiene.
At the time of this survey V23 was unable to be interviewed due to no longer being employed at the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146144
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146144
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonebridge Nursing & Rehab
902 South McLeansboro
Benton, IL 62812
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
Based on interview and record review the facility failed to have sufficient number of nursing staff to provide
nursing and related services to meet the activity of daily living needs of the residents who reside there. This
failure has the potential to affect all 61 resident who reside in this facility.
Findings included:
On 10/17/2022 at 9:30am, V1 (Administrator) presented a facility document titled Resident Census and
Condition. This document showed the facility has a census of 61 residents and of the 61 residents 59 of
them require assistance of one or two staff for transferring and 42 residents require the assistance of 1 or 2
staff for personal hygiene needs.
On 10/17/2022 at 3:30pm, V2 (Director of Nursing) said the CNAs (Certified Nursing Assistants) typically
work 8 hours shifts which include 6am to 2pm for dayshift, 2pm to 10pm for evening shift and 10pm to 6am
for night shift. After reviewing the evening shift schedule for 10/17/2022, V2 verified the facility had on
schedule, 3 CNAs (V17, V31 and V32) and V30 NA (Nursing Assistant). V2 said she felt that was enough
staff to provide care to all the residents who resided at this facility.
On 10/18/2022, the shower schedule for the the evening shift of 10/17/2022 was reviewed with V6
(Corporate Administrator). R41, R18, R36, R50, R26, R44, R49, R7 and R8 were all scheduled to receive
their showers per this schedule. V6 was asked to provide documentation of who received their scheduled
shower on the evening of 10/17/2022. V6 provided a document titled Complete Care Details a summary
lookback for 10/17/2022 for all units which listed the resident's who were bathed that day. This list
documented 4 residents (R24 (not scheduled), R26, R44 and R7) received showers. V6 said she did not
know why all the residents who were scheduled did not get showered.
On 10/20/2022 at 11:00am, V32 (CNA/Certified Nursing Assistant) said she worked the evening shift on
10/17/2022 and she gave showers to R44, R24 and R26, which she documented. V32 said she was not
sure if any other showers were given that evening.
On 10/18/2022 at 9:00am, R36 said she was scheduled to get a shower on the evening of 10/17/2022 and
she wanted her shower, but no one came to give her one. R36 said she misses a lot of showers because
there is not enough staff to give her one. R36 said she needs extensive assistance for all personal hygiene
tasks. On 10/19/2022 at 10:00am, R36 said she still had not received a shower and it had been over a
week since she was last showered. R36's medical records under MDS (Minimum Data Set) dated
9/11/2022 documents R36's BIMS (Brief Interview for Mental Status) score of 15 out of 15 indicating R36 is
cognitively intact and under section G of the MDS it documented R36 needs physical help in part for
bathing.
On 10/18/2022 at 12:15pm, R41 and R32 both alert to person, place and time were together in their room.
Both said R41 was scheduled to get a shower the evening before (10/17/2022) but no one ever came and
offered him to take a shower. Both said they are lucky to get even one shower a week and frequently don't
get that because the facility is short of staff. R41's medical record under MDS under section G and dated
9/23/2022 documented R41 did not have the bathing activity occur or was provided by family 100 % in the
previous 7 days. R32's most recent MDS documents R32 needs supervision with bathing.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146144
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146144
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonebridge Nursing & Rehab
902 South McLeansboro
Benton, IL 62812
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0725
Level of Harm - Minimal harm
or potential for actual harm
On 10/18/2022 at 12:30pm, R57 said the facility does not have enough staff. R57 said he and others do not
get showers when scheduled and they have to beg to get showered. R57 said this issue has been brought
up several times in resident council meetings but nothing is ever done about it. R57's medical records under
MDS section C and G and dated 10/7/2022 documented R57 has a BIMS of 14 indicating R57 is
cognitively intact and requires total assistance with bathing.
Residents Affected - Many
On 10/18/2022 at 12:38pm, R54 said she does not get her scheduled showers and sometimes doesn't
even get showered once per week. R54 said the facility needs more staff. R54's medical record under MDS
section C and G, dated 10/05/2022 documents R54 has a BIMS of 14 indicating R54 is cognitively intact
and needs physical help in part with bathing.
On 10/18/2022 at 12:42pm, R51 said the facility does not have enough staff to give showers and provide
proper care to the residents. R51 said she does not get her scheduled showers and often does not get
showered once per week. R51's medical record under MDS sections C and G and dated 10/12/2022
documented R51 has a BIMS of 15 indicating R51 is cognitively intact and requires total dependence with
bathing.
On 10/18/2022 at 12:48pm, R 11' s' family member said she feels the facility is short of staff and needs
more. R11's family member said some times when she comes to see R11, R11 is soaked with urine and
needs her whole bed changed and it takes a long time to get the call light answered.
On 10/17/2022 at 9:30am, R31 said there used to be 2 CNAs (Certified Nursing Assistants) assigned to
work her hall on dayshift and on evening shift but for several weeks now there has only been one assigned.
R31 stated she only gets a shower if she asks the staff for one otherwise she does not receive them. R31's
medical records under tab titled MDS section C and G dated 9/16/2022 documented R31 has BIMS of 15
indicating R31 is cognitively intact and needs physical help in part with bathing.
On 10/17/2022 at 10:01 am, R55 who was alert to person, place and time said there used to be 2 CNAs on
her hall but that has not happened for a very long time. R55 said she feels there are a lot of residents on
her hall who require extensive assistance and must be transferred with the patient lifting machine, which
requires at least two staff members to use.
On 10/17/22 at 10:33 AM, R29 stated that there is usually 2 CNAs working on her hall and lately there has
only been 1 CNA working her hall. R29 stated that she needs 2 CNAs to get her out of bed. R29 stated she
transfers using a patient lifting machine which takes 2 people to use and she must wait for another staff
member to be found before she can be transferred or showered. R29's medical records under tab MDS
sections C and G dated 8/31/2022 documented R29 has a BIMS of 15 indicating R29 is cognitively intact
and needs extensive assistance of 2+ staff for transferring and is listed as total dependence of staff for
bathing.
On 10/18/2022 at 10:36am, V16 (Registered Nurse) said the facility is short staffed on all shifts especially
CNAs (Certified Nursing Assistants).
On 10/18/2022 at 10:39am, V15, V17 and V18 (Certified Nursing Assistants) all said the facility is very short
of staff. V17 said she's worked at this facility for 2-3 years and she has always felt 3 care staff on the
evening shift is not enough staff to provide care. V17 said it didn't used to be like that but has been for
several months now. V15, V17 and V18 all said they can not complete the scheduled showers due to not
having enough time or not enough staff, but they are doing the best they can.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146144
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146144
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonebridge Nursing & Rehab
902 South McLeansboro
Benton, IL 62812
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
Based on interview, observation and record review the facility failed to provide the mechanical soft diet
texture as directed by the menu/recipe for 7 of 19 residents (R17, R30, R24, R45, R37, R13, and R15)
reviewed for dining in a sample of 55.
Findings Include:
1. The Facility document titled, Diet Spreadsheet dated week 3, Day 15 documents: Dental Soft (Mech Soft)
- Ground Chicken Salad Sandwich, Cheddar Macaroni Salad - No raw Veg (vegetables), Diced Tomato
Salad - No Raw Veg (d/s), and Pear Cobbler.
The facility document titled, Ground Chicken Salad Sandwich documents: 4. Portion #10 dipper chicken
salad on 1 sl (slice) bread. Top with 2nd slice of bread.
On 10/16/22 between 12:00 PM and 2:00 PM, R17, R30, R24, R45, R37, R13, and R15 were observed
with and eating the mechanical soft textured diet for lunch.
On 10/16/22 between 12:00 PM and 2:00 PM, R17, R30, R24, R45, R37, R13, and R15 were observed
with chicken salad sandwiches served on toast.
2. The Facility document titled, Diet Spreadsheet dated week 3, Day 16 documents: Dental Soft (Mech Soft)
- Ground Hamburger on Bun, Soft baked french fries, creamed corn, and soft canned diced fruit.
The facility document titled, Ground Hamburger on Bun documents: Portion #10 dip ground beef onto each
bun. Top ground beef with 1-2 ounces of prepared gravy, as needed, to serve the meat moist.
On 10/17/22 between 12:00 PM and 1:30 PM, R17, R30, R24, R45, R37, R13, and R15 were observed
with and eating the mechanical soft textured diet for lunch.
On 10/17/22 between 12:00 PM and 1:30 PM, R17, R30, R24, R45, R37, R13, and R15 were observed
with ground hamburger on a bun with no gravy.
On 10/17/22 at 11:23 PM, V20 (Therapy Director/ Speech Language Pathologist) stated, the residents with
the mechanical soft diet should not receive their sandwiches on toast, that would be considered a regular
diet food item. The directions on recipe for the item should always be followed.
On 10/20/22 at 1:00 PM, V8 (Dietary Manager) stated, she did not realize the chicken salad was suppose
to be served on bread and that the hamburger for the mechanical soft diet was suppose to have gravy on it.
R17's Physician order sheet for 10/01/22 with a start date of 05/28/22 documents a Mechanical Soft diet.
R30's Physician order sheet for 10/01/22 with a start date of 07/05/22 documents a Mechanical Soft diet.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146144
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146144
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/20/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stonebridge Nursing & Rehab
902 South McLeansboro
Benton, IL 62812
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
R24's Physician order sheet for 10/01/22 with a start date of 08/26/22 documents a Mechanical Soft diet.
Level of Harm - Minimal harm
or potential for actual harm
R45's Physician order sheet for 10/01/22 with a start date of 08/26/22 documents a Mechanical Soft diet.
R37's Physician order sheet for 10/01/22 with a start date of 06/28/22 documents a Mechanical Soft diet.
Residents Affected - Some
R13's Physician order sheet for 10/01/22 with a start date of 10/04/21 documents a Mechanical Soft diet.
R15's Physician order sheet for 10/01/22 with a start date of 03/09/20 documents a Mechanical Soft diet.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146144
If continuation sheet
Page 10 of 10
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0222GeneralS&S Epotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
FAQ · About this visit
Common questions about this visit
What happened during the October 20, 2022 survey of STONEBRIDGE NURSING & REHAB?
This was a inspection survey of STONEBRIDGE NURSING & REHAB on October 20, 2022. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at STONEBRIDGE NURSING & REHAB on October 20, 2022?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide care and assistance to perform activities of daily living for any resident who is unable."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.