Health inspection·November 30, 2023

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that 17 multiple bed resident rooms on the South hall and 14 multiple bed resident rooms on the North hall provided the required 80 square feet per resident bed for 41 of 41 (R19, R7, R14, R28, R3, R11, R5, R36, R33, R31, R4, R26, R20, R39, R22, R18, R8, R9, R21, R34, R38, R30, R15, R6, R17, R18, R29, R12, R24, R37, R35, R1, R16, R32, R195, R196, R146) residents reviewed for room size in the sample of 44. Findings include: On 11/28/23 at 9:10 AM, V1 (Director of Operations) stated, that all waivered rooms measure less than 80 square feet per resident and are Medicaid Certified. The waivered rooms on the south hall are rooms [ROOM NUMBER]-20; and north hall rooms 1-14. On 11/28/23 at 11:30 AM, V5 (Maintenance) measured rooms 1, 3, 6-20 on the south hall. Rooms 1, 3, 6-20 are certified 2 bedrooms measuring 12.4 feet by 11.8 feet equaling 146 square feet, which is approximately 73 square feet per resident bed. Rooms 1, 3, 10, 14, and 16 contained 1 dresser, 1 bed and 1 nightstand. Rooms 6, 7, 8, 9, 11, 12, 13, 15, 17, 18, 19, and 20 contained 1 dresser, 2 beds, 2 nightstands. There were no concerns observed with space in any of these waivered rooms. On 11/28/23 at 11:30 AM, R26 stated she does not have any concerns with the room size. R26 is alert and oriented to person, place, and time. On 11/28/23 at 11:40 AM, V5 measured rooms 1-14 on the north hall. Rooms 1-14 are certified 2 bedrooms measuring 12.4 feet by 11.8 feet equaling 143 square feet total space, which is approximately 71.5 square feet per resident per room. Rooms 1, 6, 7, 8, 9, contained 1 dresser, 2 beds, and 2 nightstands. Rooms 2, 3, 4, 5, 10, 11, 12, 13, 14, contained 1 dresser, 1 bed and 1 nightstand. There were no concerns observed with space in any of these waivered rooms. On 11/28/23 at 11:43 AM, R20 & R39 stated they do not have any concerns with the room size. R20 & R39 are alert and oriented to person, place, and time. On 11/28/23 at 11:45 AM, R9 stated she does not have any concerns with the room size. R9 is alert and oriented to person, place, and time. On 11/28/23 at 11:47 AM, R21 stated she does not have any concerns with the room size. R21 is alert and oriented to person, place, and time. Page 1 of 2 146144 146144 11/30/2023 Stonebridge Nursing & Rehab 902 South McLeansboro Benton, IL 62812

F 0912 Level of Harm - Potential for minimal harm On 11/28/23 at 11:50 AM, R30 stated she does not have any concerns with the room size. R30 is alert and oriented to person, place, and time. On 11/28/23 at 11:52 AM, R15 stated she does not have any concerns with the rooms size. R15 is alert and oriented to person, place, and time. Residents Affected - Some On 11/28/23 at 11:54 AM, R146 stated she does not have any concerns with the rooms size. R146 is alert and oriented to person, place, and time. On 11/28/23 at 11:56 AM, R24 stated she does not have any concerns with the rooms size. R24 is alert and oriented to person, place, and time. On 11/28/23 at 11:58 AM, R16 stated she does not have any concerns with the rooms size. R16 is alert and oriented to person, place, and time. On 11/28/23 at 12:00 PM, R32 stated she does not have any concerns with the rooms size. R32 is alert and oriented to person, place, and time. On 11/28/23 at 12:03 PM, R19 stated he does not have any concerns with the rooms size. R19 is alert and oriented to person, place, and time. On 11/28/23 at 12:07 PM, R7 stated she does not have any concerns with the rooms size. R7 is alert and oriented to person, place, and time. On 11/28/23 at 12:09 PM, R14 stated she does not have any concerns with the rooms size. R14 is alert and oriented to person, place, and time. On 11/28/23 at 12:11 PM, R28 stated she does not have any concerns with the rooms size. R28 is alert and oriented to person, place, and time. On 11/28/23 at 12:13 PM, R195 and R5 stated they do not have any concerns with the room's size. R195 and R5 were alert and oriented to person, place, and time. On 11/28/23 at 12:17 PM, R11 stated she does not have any concerns with the rooms size. R11 is alert and oriented to person, place, and time. The facility Daily Roster, dated 11/27/23, documents R19, R7, R14, R28, R3, R11, R5, R36, R33, R31, R4, R26, R20, R39, R22, R18, R8, R9, R21, R34, R38, R30, R15, R6, R17, R18, R29, R12, R24, R37, R35, R1, R16, R32, R195, R196, R146 reside in rooms1, 3, and 6-20 on the south hall and rooms1-14 on the north hall. Observations of the waivered rooms, from 11/27/23 through 11/30/23, shows these rooms provide adequate space to meet the medical and personal needs of these residents. The Resident Council Meeting Minutes, dated 9/23 through 11/23, documents no complaints regarding the waivered room space. 146144 Page 2 of 2