Inspection·September 2, 2025

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many told V7 that R3 wasn't having a very good day today. On 8/26/25 at 1:47 PM, V6 stated R3 doesn't usually need assistance eating but she isn't having a very good day today, so she was going to try and get her to eat some. On 8/26/25 at 2:02 PM, V8 (CNA) stated R3 usually feeds herself but she has been struggling lately and hasn't been eating much. V8 stated she hasn't checked on her since her tray was delivered because she has been shaving 3 other residents and hasn't had time. 4. R11's admission Record documents an admission date of 12/5/23 with diagnoses including in part: fracture of lower end of right tibia, obesity, chronic pain syndrome, primary osteoarthritis, muscle weakness, other abnormalities of gait and mobility, unsteadiness son feet, and need for assistance with personal care. R11's MDS dated [DATE] documents a BIMS of 15, indicating R11's cognition is intact. The same MDS documents R11 is dependent for chair/bed-to-chair transfers. The MDS documents depends as, helper does all the effort and resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. On 8/26/25 at 9:20 AM, R11 stated she is a mechanical lift now because she fell about 2 months ago while being transferred and broke her knee. R11 stated she usually has a long wait for her call light to be answered, sometimes 30 minutes or longer and stated she has urinated on herself before because she had to wait so long. On 8/26/25 at 12:40 PM, R11 said the CNAs usually get her up with one assist using the mechanical lift. On 8/26/25 at 12:40 PM, V4 (CNA) stated she got R11 up today with the mechanical lift by herself. This surveyor asked V4 why she did it by herself and V4 stated because there wasn't anyone else to help. 5.R12's admission Record documents an admission date of 7/18/25 with diagnoses including in part: displaced intertrochanteric fracture of left femur, anxiety, restlessness and agitation, major depressive disorder, dementia severe with other behavioral disturbance, and sensorineural hearing loss. R12's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview of Mental Status (BIMS) of 99 indicating the interview was not completed. The same MDS documents R12 is supervision or touching assistance for toilet transfer and sitting to standing. R12's current Care Plan documents R12 is at risk for fall with interventions including in part: call light within reach and observe for unsafe actions and intervene. The same Care Plan documents R12 has a self-care deficit with interventions including in part: assist with toileting and showers/bath. On 8/26/25 at 12:02 PM, constant observation, R12's bed alarm was going off at 12:02, R12 was yelling for help stating he needed to urinate and was going to urinate in his pants because he had to go so bad, there was no staff in the hallway. R12's call light was laying over the nightstand, out of reach. At 12:04 R12 reached for his trashcan and pulled it over to him, pulled down his pants and was trying to urinate in the trashcan, there was still no staff in the hallway until 12:08 PM. At 12:08 V5 (Activities Director) walked past R12's room then turned around and came back and told R12 she would get someone to help. At 12:09 V3 (Corporate Nurse) came down the hall to give this surveyor a document and heard the bed alarm and went into R12's room to assist. V3 came out of the resident's room and was asked who would have answered that bed alarm if she wasn't coming to find this surveyor and V3 stated I would hope the staff would.6. R4's admission Record documents an admission date of 9/30/24 with diagnoses including in part: atherosclerosis of aorta, difficulty in walking, other abnormalities of gait and mobility, history of falling, and tobacco use. R4's MDS dated [DATE] documents a BIMS of 08, indicating moderately impaired cognition. On 8/26/25 at 8:47 AM, R4 stated call light wait time can be long at times. R4 stated I am concerned if there was a real problem I might be dead before they get to me to answer my call light. On 8/26/25 at 11:04 AM, V9 (CNA) stated she feels like residents to not get the care they when they are short staffed, and V9 stated she feels like they are short on staff now. V9 stated they only have 4 CNA's working today and she doesn't think that is enough. V9 stated she can't always (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146144 If continuation sheet Page 2 of 3 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 09/02/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete get to the residents right away when they need something. On 8/26/25 at 11:06 AM, V10 (CNA) stated she feels like residents are not getting the care needed when they are short staffed, and she stated there is only 4 CNAs working today and she doesn't think that is enough. V10 stated she doesn't think she is able to provide the best care when they don't have enough CNA staff, and she feels that is true right now. V10 was asked about 2 call lights that were currently on, and she stated they are on all the time, but we have higher priority things that need done right now. On 8/26/25 at 11:56 AM, V4 (CNA) stated there are days they have enough staff and days they don't. V4 stated weekends seems to be worse. V4 stated there are times she can't give showers due to not enough staff. V4 stated she feels like residents are not getting the care needed on days they are short staffed because they might not get their showers. V4 stated there are only 4 CNAs working today. On 8/26/25 at 1:13 PM, V1 (Administrator) stated there is someone from the management team here during the day 7 days a week, but not at night unless it is needed. V1 stated ideal staffing is 6 CNAs from 6am-2pm, 5 CNAs from 2pm-10pm, and 4 CNAs from 10p-6a. V1 stated they are having some difficulties with staffing right now due to staff being out with COVID. V1 stated the CNAs shifts were switched to 12 hour shifts to help cover. V1 stated all mechanical lift transfers should be completed using 2 staff assist. A facility document titled Daily Census dated 8/25/25 documents total number of residents that reside in the facility is 56. A facility policy titled Staffing dated October 2017 documents under Policy Statement: Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment and under Policy Interpretation and Implementation: 5. Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee. Event ID: Facility ID: 146144 If continuation sheet Page 3 of 3