Inspection·December 19, 2024

F 0912 Level of Harm - Potential for minimal harm Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation, interview, and record review the facility failed to provide at least 80 square feet of living space for 4 of 4 residents (R20, R21, R27, R38) reviewed for room size in a sample of 32. Residents Affected - Some Findings include: On 12/18/24 at 10:15 AM, V1 (Administrator) stated that rooms 1-14 on the North Hall and rooms 1, 3, 6-20 on the South Hall provide less than 80 square feet per resident bed and are all Medicaid Certified rooms. On 12/18/24 at 10:30 AM, V6 (Maintenance) measured R27 and R38's room on the south hall with a measuring tape, the bedroom measured 12.4 feet by 11.8 feet equaling 146 square feet, which is approximately 73 square feet per resident. R27 and R38's room contained 1 dresser, 2 beds and 2 nightstands. On 12/18/24 at 10:45 AM, R27 and R38 were in their room. The room was a smaller sized bedroom with two beds, 2 night stands and an inset dresser in the room. at that time R27 who was alert to person, place and time stated she does not have any concerns with the room size. R38 was in the room but was non-interviewable. On 12/18/24 at 11:40 AM, V6 measured R20 and R21's room on the north hall. This room was measured with a measuring tape and measured 12.4 feet by 11.8 feet equaling 143 square feet total space, which is approximately 71.5 square feet per resident. This room contained 1 inset dresser, 2 beds, and 2 nightstands. There were no concerns observed with space in this waivered room. On 12/18/24 at 11:45 AM, R20 stated she does not have any concerns with her room size. R20 was alert and oriented to person, place, and time. On 12/18/24 at 11:55 AM, R21 stated she does not have any concerns with her room size. R21 was alert and oriented to person, place, and time. The facility Daily Roster, dated 12/16/24, documents R20, R21, R27, and R38 reside in the rooms observed and measured by V6. Observations of the waivered rooms, from 12/16/24 through 12/19/24, show these rooms provide adequate space to meet the medical and personal needs of these residents. The Resident Council Meeting Minutes, dated 9/24 through 11/24, documents no complaints regarding (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 12/19/2024 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)