Center For Living & Rehabilitation
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Based on interview and record review the facility failed to ensure that one of three residents in the applicable sample, (Resident #1) were free from accidents and hazards, causing the Resident to sustain a skin tear. Per record review on 7/4/2025 Resident #1 was found by staff in bed with a large skin tear on her/his right lower leg. Resident #1 had a care plan focus of ADL (activities of daily living) self-care deficit with a transfer status of 2 staff assist that was implemented on 10/20/2024. Per review of the facility's internal investigation, it states that Resident #1 was care planned for a 2 person stand pivot transfer to all surfaces and for Dermasaver skin tubes (used to protect skin from injury) to always be on when out of bed.
The Dermasavers are to be removed only when s/he has been safely transferred back into bed. The investigation further states that Resident #1 had been out of bed in their wheelchair for dinner and was assisted with her/his meal by a nurse. The next time Resident #1 was observed was back in bed by their primary Licensed Nursing Assistant (LNA) when the skin tear was discovered. Per review of staff statements obtained by the facility during the internal investigation the LNA who was assigned to Resident #1's care stated that she had transferred the Resident out of bed to chair for dinner by herself but did not transfer the Resident back to bed. Per interview on 8/27/2025 at 4:10 PM the Director of Nursing confirmed that a staff member had transferred Resident #1 independently and that the Resident had been care planned for 2-assist with transfers. It had been determined through the facility's internal investigation that
the skin tear occurred during this transfer.
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
Event ID:
Center for Living & Rehabilitation in Bennington, VT inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Bennington, VT, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Center for Living & Rehabilitation or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.