Center for Living & Rehab: Safety Hazard Cited - VT
The incident at Center for Living & Rehabilitation occurred on July 4, 2025, when staff found Resident #1 in bed with the injury to their right lower leg. The resident's care plan, implemented since October 20, 2024, specifically required two staff members for all transfers due to an activities of daily living self-care deficit.
The resident had been out of bed in their wheelchair for dinner and received meal assistance from a nurse. When their primary Licensed Nursing Assistant later checked on them in bed, she discovered the skin tear.
Federal inspectors reviewed the facility's internal investigation, which revealed the breakdown in safety protocols. The resident's care plan mandated two-person stand pivot transfers to all surfaces. Additionally, the resident was supposed to wear Dermasaver skin tubes whenever out of bed to protect against injury. These protective devices could only be removed after the resident had been safely transferred back to bed.
The LNA assigned to the resident's care admitted during staff interviews that she had transferred the resident from bed to chair for dinner by herself. However, she stated she did not transfer the resident back to bed, leaving unclear who performed that second transfer and when the injury occurred.
The facility's investigation determined the skin tear happened during one of these transfers. The Director of Nursing confirmed to federal inspectors on August 27 that a staff member had indeed transferred the resident independently, violating the two-person requirement established in the care plan.
This case illustrates how ignoring established safety protocols can lead directly to resident injury. The resident's care plan existed specifically because they required additional assistance and protection during transfers. The Dermasaver skin tubes were prescribed as an additional safeguard against the exact type of injury that occurred.
The investigation revealed gaps in both the transfer process and subsequent documentation. While the LNA admitted to performing the initial transfer alone, no staff member took responsibility for the return transfer to bed where the injury was ultimately discovered.
Federal inspectors cited the facility for failing to ensure residents remain free from accident hazards and for inadequate supervision to prevent accidents. The violation affected few residents but represented minimal harm or potential for actual harm under federal nursing home regulations.
The timing of the discovery raises additional questions about supervision and monitoring. The resident was assisted with dinner by a nurse, suggesting staff interaction, yet the injury went unnoticed until the primary LNA's later check. This gap indicates potential lapses in the continuous observation required for residents with documented transfer assistance needs.
Care plans exist as binding protocols designed to prevent exactly these types of preventable injuries. When a resident requires two-person transfers, that requirement reflects an assessment of their physical limitations and fall risk. Ignoring such protocols puts vulnerable residents at direct risk of harm.
The facility's internal investigation, while thorough in documenting what happened, highlighted systemic issues with protocol compliance. Staff members clearly understood the two-person requirement, yet chose to violate it anyway, suggesting either inadequate training, insufficient staffing, or poor supervision of care plan implementation.
For Resident #1, the violation of established safety measures resulted in a painful injury that could have been prevented through simple adherence to their documented care requirements. The skin tear serves as a tangible reminder of why nursing homes establish detailed care plans and why staff compliance with those plans remains essential for resident safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Center For Living & Rehabilitation from 2025-08-28 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 20, 2026 · Our methodology
Center for Living & Rehabilitation in Bennington, VT was cited for violations during a health inspection on August 28, 2025.
The incident at Center for Living & Rehabilitation occurred on July 4, 2025, when staff found Resident #1 in bed with the injury to their right lower leg.
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.