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. (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 2 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 11/30/2023 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)