Stonebridge Nursing & Rehab: Staffing Failures Cited - IL
"They are on all the time," the aide, identified in the inspection report as V10, said during a visit on August 26. "But we have higher priority things that need done right now."
There were four CNAs working that morning to care for 56 residents. The facility's own standard calls for six.
The inspection, conducted September 2 following a complaint, found that Stonebridge had failed to maintain sufficient nursing staff to meet residents' needs. Federal inspectors rated the violation as carrying potential for actual harm and affecting many residents.
V10 said she doesn't believe residents receive the care they need on short-staffed days. She was direct about it: "I feel like residents are not getting the care needed when they are short staffed." She said she doesn't think four CNAs is enough, and she doesn't think she is able to provide her best care under those conditions. She said that was true right now, in the moment the inspector was standing there.
A second aide, V4, described the same shift and the same headcount. Four CNAs. She said weekends tend to be worse. On days without enough staff, she told the inspector, she sometimes cannot give residents their showers. "She feels like residents are not getting the care needed on days they are short staffed because they might not get their showers."
The administrator, V1, confirmed the staffing targets the facility sets for itself: six CNAs on the day shift running from 6 a.m. to 2 p.m., five on the afternoon shift, four overnight. V1 said the facility had been struggling with staffing because employees were out with COVID. To compensate, management had switched CNA shifts from eight hours to twelve.
V1 also noted that all mechanical lift transfers, used to move residents who cannot bear their own weight, require two staff members. On a day when four aides are covering a 56-bed facility, the math on that is unforgiving.
The administrator said someone from the management team is present during the day seven days a week, but not at night unless needed.
A facility policy on staffing, dated October 2017, states that Stonebridge provides "sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents." The same document instructs that concerns about staffing should be directed to the administrator. The aides who spoke to inspectors had apparently reached their own conclusions about whether the policy matched reality.
What the inspection report captures is not a single bad day. V4 described it as a pattern, worse on weekends, recurring whenever call-outs stack up. V10 described it as the present condition, happening in real time while the inspector watched lights blink unanswered in the hallway.
Call lights exist because residents cannot always get up, cannot always wait, and sometimes cannot afford to. A resident who needs help to the bathroom and cannot get an aide may not make it in time. A resident who needs repositioning to avoid a pressure wound may lie in the same position for hours. A resident who requires a two-person mechanical lift and has only one aide available may not be moved at all. The inspection report does not document specific residents harmed. It documents a staffing level that the facility's own workers said made harm more likely.
The daily census from August 25 put the resident count at 56. Four CNAs. Two call lights on, unanswered, while the aide who knew about them moved on to something else.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stonebridge Nursing & Rehab from 2025-09-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
STONEBRIDGE NURSING & REHAB in BENTON, IL was cited for violations during a health inspection on September 2, 2025.
"They are on all the time," the aide, identified in the inspection report as V10, said during a visit on August 26.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.