Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stonebridge Nursing & Rehab during CMS and state inspections, most recent first.
Improper Texture for Mechanical Soft Diets: A dietary service failed to serve chopped Brussel sprouts and chopped peach parfait items in the required bite-sized texture for residents ordered a mechanical soft/dental soft diet. During tray plating, the vegetables and fruit were observed served whole or in large pieces, and the Dietary Mgr confirmed they should have been chopped for the ordered texture.
Insufficient room space for multiple residents: Maintenance measured two shared rooms and found each provided less than 80 sq ft per resident, with one room at about 73 sq ft per resident and another at about 71.5 sq ft per resident. The rooms contained beds, nightstands, and dressers, and the Administrator stated several North and South Hall rooms were Medicaid certified rooms with less than 80 sq ft per bed. One resident in each room reported no concerns, while the other residents were present but not able to be interviewed.
Laundry Room Wall Deterioration and Mold-Like Substance: Surveyors observed a wall behind the washer with water damage, damp broken areas, cove base trim lying over a water-filled grate, and a black mold-like substance near the hoses. A Laundry staff member said the wall had been falling apart for a long time and had gotten wet several times, while the Maintenance Director confirmed a leak behind the washer and said the damage was likely from water exposure. The Administrator stated the damage was most likely from washer leakage or drain overflow.
Multiple residents experienced significant delays in receiving care due to insufficient CNA staffing, resulting in unmet needs such as assistance with meals, transfers, toileting, and participation in scheduled activities. Staff interviews and observations confirmed that the number of CNAs on duty was below the facility's stated ideal, leading to missed care and staff performing tasks alone that require two-person assistance.
A resident with a history of stroke and severe cognitive impairment was admitted with a Stage IV pressure ulcer, but staff failed to obtain and document timely physician orders for wound care. Nursing staff applied treatments without consistent documentation or clear orders, and required wound assessments and treatment details were not recorded as per facility policy.
The facility failed to provide the required 80 square feet of living space per resident in shared rooms, affecting four residents. Rooms measured approximately 146 and 143 square feet, providing only about 73 and 71.5 square feet per resident. Despite this, the residents expressed no concerns, and observations showed no complaints about the space.
Improper Texture for Mechanical Soft Diets
Penalty
Summary
The facility failed to serve foods in the texture directed by the physician for 15 residents who were ordered a mechanical soft, or dental soft, diet. The report states that the facility’s diet spreadsheet for lunch included chopped Brussel sprouts and a chopped peach parfait, and the dietary instructions for both items required the food to be cut or chopped into bite-sized pieces for residents on this texture-modified diet. During observation of tray plating in the kitchen on 12/15/25 at 12:05 PM, the Brussel sprouts were served whole, approximately one inch in diameter or larger, and the peach slices were over an inch to over two inches in length for residents receiving a mechanical soft diet. On 12/18/25, the Dietary Manager stated the Brussel sprouts and peaches served on 12/15/25 should have been chopped before serving for the mechanical soft diet. The diet roster identified the affected residents as receiving dental soft (mechanical soft) diets, and the facility policy stated that if a mechanically altered diet is ordered, the provider will specify the texture modification.
Insufficient Room Space for Multiple Residents
Penalty
Summary
The facility failed to provide at least 80 square feet of living space per resident for 4 of 4 residents reviewed for room size in a sample of 36. On 12/17/25, the 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 Medicaid certified rooms. The Daily Roster dated 12/15/25 documented that the four residents lived in the rooms that were observed and measured by maintenance staff. Maintenance measured two shared rooms with a tape measure. One room occupied by two residents measured 12.4 feet by 11.8 feet, totaling 146 square feet, or approximately 73 square feet per resident, and contained 1 dresser, 2 beds, and 2 nightstands. Another room occupied by two residents measured 12.4 feet by 11.8 feet, totaling 143 square feet, or approximately 71.5 square feet per resident, and contained 1 inset dresser, 2 beds, and 2 nightstands. One resident in each room stated she had no concerns with the room size, while the other residents were present but not able to be interviewed. Observations from 12/15/25 through 12/18/25 documented that these waivered rooms provided adequate space to meet the medical and personal needs of the residents, and Resident Council Meeting Minutes from 9/25 through 11/25 documented no complaints regarding the waivered room space.
Laundry Room Wall Deterioration and Mold-Like Substance
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in the laundry room by allowing the wall behind the washer to deteriorate from water damage. On 11/17/25 at 6:05 AM, surveyors observed what appeared to be a black mold-like substance on the wall next to the washer hoses. They also observed the bottom part of the wall falling apart and damp, with the cove base trim lying over a grate that contained water, and a moldy-like substance on the wet broken wall area. During interviews on 11/18/25, the Laundry staff member stated the wall behind the washer had been falling apart and had mold-looking material on it for a long time, and said the wall had gotten wet several times. The Maintenance Director stated he knew there was a water leak behind the washer because he had to change some hoses, did not know how long the wall had been deteriorating, and said the wall would be replaced on 11/21/25. The Administrator stated the damage was most likely due to water from the washer leaking or the drain overflowing. The facility policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment, and the daily census showed 53 residents in the facility.
Failure to Provide Sufficient Nursing Staff for Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents in a timely manner, as evidenced by multiple observations, interviews, and record reviews. Several residents were observed waiting extended periods for assistance after activating their call lights. One resident was seen with his call light on for an extended period before it was answered by a corporate nurse, while another resident reported waiting up to an hour for assistance and missing scheduled activities due to the delay. Staff interviews confirmed that there were only four CNAs working on the day of observation, which was considered insufficient by both staff and residents. Residents with varying degrees of physical and cognitive impairment were directly affected by the staffing shortage. One resident, who required assistance with eating, was left with an untouched meal tray for over an hour and only received help after a family member and a staff member intervened. Another resident, dependent on a mechanical lift for transfers, reported long waits for assistance and instances of incontinence due to delays. A CNA admitted to performing a mechanical lift transfer alone, contrary to policy, because no other staff were available to help. Additional observations included a resident with a bed alarm and call light out of reach, who was left unattended while urgently needing to use the restroom. The resident attempted to use a trashcan to urinate after calling for help for several minutes without response. Staff interviews consistently indicated that the current staffing levels were inadequate to meet resident needs, with some care tasks, such as showers, being missed on short-staffed days. The facility's own staffing policy and administrator statements confirmed that the number of CNAs present was below the ideal level, and the issue was exacerbated by staff absences due to illness.
Failure to Obtain and Document Timely Wound Care Orders for Pressure Ulcer
Penalty
Summary
A deficiency occurred when the facility failed to obtain and implement physician orders for wound care for a resident who was admitted with a Stage IV pressure ulcer. The resident, who had a history of stroke with right-sided paralysis and severe cognitive impairment, was admitted from the hospital with a pressure area on the coccyx. Upon admission, there were no measurements or descriptions of the wound documented in the admission screener or nurse progress notes. Additionally, there were no wound care orders in place from the time of admission until several days later. Multiple nursing staff members acknowledged that the resident returned with a wound, but wound care treatments were not documented on the Treatment Administration Record (TAR) until several days after admission. Staff reported using various wound care products, such as Silvadene and calcium alginate, but could not consistently recall if or when physician orders were obtained or documented. Some staff believed they had communicated with a physician or nurse practitioner, but there was no clear record of timely orders or documentation in the resident's medical record. Facility policies required that verbal or telephone orders be documented by licensed personnel and that treatment orders specify the treatment, frequency, and duration. Policies also required a full assessment and documentation of pressure ulcers, including measurements and wound characteristics. These procedures were not followed, resulting in a lack of timely and appropriate wound care orders and documentation for the resident.
Deficiency in Room Size for Multiple Residents
Penalty
Summary
The facility failed to provide the required minimum living space of 80 square feet per resident in multiple occupancy rooms for four residents. During the survey, it was observed that rooms on both the North and South Halls did not meet the required space standards. Specifically, rooms measured approximately 146 square feet and 143 square feet, which equates to about 73 and 71.5 square feet per resident, respectively. These rooms contained two beds, nightstands, and dressers, indicating a lack of adequate space per resident. Despite the deficiency in room size, the residents involved, who were alert and oriented, expressed no concerns regarding the space. The facility's daily roster confirmed the residency of the individuals in the measured rooms. Additionally, observations over several days and Resident Council Meeting Minutes from previous months showed no complaints about the room sizes, suggesting that the residents' medical and personal needs were being met despite the space limitations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Benton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benton Rehabilitation And Health Care Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Helia Healthcare Of Benton | 1.9 mi | ★★★★★ | 1 | 0 |
| Axiom Healthcare Of West Frankfort | 6.1 mi | ★★★★★ | 27 | 0 |
| Shawnee Senior Living | 13.1 mi | ★★★★★ | 5 | 0 |
| Integrity Hc Of Herrin | 13.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.