Benton Rehab: Lung Tests Done Without Doctor Orders - IL
The therapist, identified in inspection records as V22, told inspectors she went to the facility in March 2025 and performed the tests. When asked whether physician orders were in place beforehand, she said the facility told her there were. She never saw the actual orders.
There weren't any documented in the medical records.
One resident, identified as R16, had PFT results in her file dated March 20, 2025. Her care profile contained no physician order for the testing. When inspectors spoke with her on September 29, she said she didn't remember whether she had the tests done.
The MDS Coordinator, V6, was direct about what had happened. Pulmonary function tests, she told inspectors, had been done on residents without physician orders in the past. She said the respiratory therapist had shown up again that same week to do more and was turned away because the orders still weren't there.
A registered nurse on staff, V12, explained the arrangement: an outside company sends a respiratory therapist to the facility to perform PFT testing on residents. As far as she knew, they had done it twice, testing everyone in the facility both times. When inspectors asked why the facility was testing all residents, V12 said she didn't know. She confirmed there were no physician orders and said that when the therapist came in most recently, the physician, V21, refused to sign off on the orders.
A licensed practical nurse, V20, offered some explanation for the physician's refusal. She didn't think V21 felt the tests were necessary and didn't want all residents to have them. She said the administrator, V1, had asked nurses to get V21 to sign the orders. He refused.
The administrator told inspectors the oxygen supply company sends the respiratory therapist to the facility to conduct the tests. She framed the testing as a quality initiative, saying they were screening residents to see if anyone had undiagnosed COPD. She said her corporate regional contact described it as the gold standard of care and that anyone without a COPD diagnosis should be screened upon admission.
The Director of Nurses, V5, acknowledged that physician orders should be in place before PFT tests are performed on residents. She told inspectors she wasn't sure why orders weren't documented in the medical records for the tests performed in March.
The physician, V21, told inspectors on September 30 that he didn't remember whether he had given orders for the PFT testing in March 2025.
The administrator offered a partial explanation for the missing documentation: the facility was owned and operated by a different company in March 2025, and no policy was available covering physician orders from that time period.
What the inspection record shows is a respiratory therapist entering the facility and conducting medical tests on an undetermined number of residents, with no documented authorization from any physician, while the therapist herself assumed the paperwork existed somewhere she hadn't seen. The physician who eventually learned of the ongoing testing refused to authorize more. The nurse who knew the orders were missing didn't know why the tests were being done in the first place. The administrator who directed nurses to obtain the physician's signature couldn't get it.
The oxygen supply company's therapist was turned away on her most recent visit. The residents tested in March still have results in their files that no doctor ordered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Benton Rehabilitation and Health Care Center from 2025-09-30 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: June 26, 2026 · Our methodology
Benton Rehabilitation and Health Care Center in BENTON, IL was cited for violations during a health inspection on September 30, 2025.
The therapist, identified in inspection records as V22, told inspectors she went to the facility in March 2025 and performed the tests.
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.