Inspection·September 30, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure physician orders were obtained prior to performing pulmonary function tests (PFT) for 4 of 4 residents (R11, R13, R15, R16) reviewed for physician orders in the sample of 17. Findings Include:1.R11's admission Record with a print date of 9/29/25 documents R11 was admitted to the facility on [DATE] with diagnoses that include chronic respiratory failure, heart failure, and chronic obstructive pulmonary disease. R11's MDS (Minimum Data Set) dated 8/23/25 documents a BIMS (Brief Interview for Mental Status) score of 13, indicating R11 is cognitively intact. R11's current Care Plan documents a Focus Area of Respiratory: DX (diagnosis) COPD, Respiratory failure .Date Initiated: 09/17/2024. This Focus area includes interventions of, Bipap as ordered Date Initiated: 02/18/2025 .Meds/Labs/Treatments as Ordered/Accepted Date Initiated: 09/17/2024. Encourage/assist with Oxygen as ordered/accepted/needed. Date Initiated: 09/17/2024 .On 9/29/25, V1 (Administrator) provided this surveyor R11's Pulmonary Function Test results dated 3/20/25. R11's undated Care Profile does not document a physician order to perform PFT testing on or near 3/20/25. On 9/29/25 at 2:23 PM, R11 stated he doesn't remember if he had a pulmonary function test done.2. R13's admission Record with a print date of 9/29/25 documents R13 was admitted to the facility on [DATE] with diagnoses that include diabetes, peripheral vascular disease, heart failure, hypertension, and anemia. R13's MDS dated [DATE] documents a BIMS score of 15, indicating R13 is cognitively intact. R13's current Care Plan does not address a Focus area related to respiratory diagnoses. On 9/29/25, V1 (Administrator) provided this surveyor R13's Pulmonary Function Test results dated 3/20/25. R13's undated Care Profile does not document a physician order to perform pulmonary function test on or near 3/20/25. On 9/29/25 at 2:27 PM, R13 stated she had PFT test done a few months ago and didn't have any concerns with it. 3. R15's admission Record with a print date of 9/29/25 documents R15 was admitted to the facility on [DATE] with diagnoses that include diabetes, dementia, hypertension, and delusional disorder. R15's MDS dated [DATE] documents a BIMS score of 09, indicating a moderate cognitive deficit. R15's current Care Plan documents a Focus area of, Respiratory: Dx-COPD Sleep apnea Date Initiated: 03/26/2025. The interventions for this Focus area include, Meds/Labs/Treatments as ordered/Accepted. Date Initiated: 03/26/2025.On 9/29/25, V1 (Administrator) provided this surveyor R15's Pulmonary Function Test results dated 3/20/25. R15's undated Care Profile does not document a physician order to perform pulmonary function tests on or around 3/20/25. On 9/29/25 at 2:34 PM, R15 denied concerns with the PFT testing that was performed. 4. R16's admission Record with a print date of 9/29/25 documents R16 was admitted to the facility on [DATE] with diagnoses that include diabetes, heart failure, hypertension, and COPD. R16's MDS dated [DATE] documents a BIMS score of 11, indicating a moderate cognitive deficit. R16's current Care Plan documents a Focus area of, Respiratory: Dx-Respiratory failure with hypoxia COPD. Date Initiated: 02/11/2025. This Focus area includes the intervention of, Meds/Labs/Treatments as Ordered/Accepted, Date Initiated: 02/11/2025.On 9/29/25, V1 (Administrator) Residents Affected - Some (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 146121 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 146121 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Benton Rehabilitation and Health Care Center 1409 North Main Street 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)