Benton Rehab: Unauthorized Lung Tests on Residents - IL
The tests were arranged through the facility's oxygen supply company, which sends a respiratory therapist to screen residents for chronic obstructive pulmonary disease. The administrator told inspectors the practice came from corporate guidance, describing it as "the gold standard of care," and said anyone without a COPD diagnosis should be screened upon admission.
The physician on staff disagreed. When the respiratory therapist returned to run more tests the following week, he wouldn't sign the orders. A licensed practical nurse told inspectors the physician didn't think the tests were necessary and didn't want all residents subjected to them. The administrator had asked nurses to get him to sign. He refused.
The respiratory therapist who performed the March tests, interviewed by inspectors, said the facility told her orders were in place before she began. She never saw them. The director of nurses said orders should have been in place and told inspectors she wasn't sure why none were documented in the medical records for the tests performed on March 20, 2025.
The MDS coordinator put it plainly: pulmonary function tests had been done on residents without physician orders in the past.
When inspectors pressed the administrator on the March testing, she said the facility had been owned and operated by a different company at that time and that no policy was available covering physician orders for that period. The physician, asked whether he had authorized the March tests, said he didn't remember.
The inspection was conducted as a complaint investigation. The finding was cited at a level of minimal harm or potential for actual harm, with some residents affected.
Nobody at the facility could produce an order. The doctor who was supposed to sign one had already said no.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 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 physician on staff disagreed.
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.