Livingston Health & Rehab: Abuse Reporting Failures - MT
The August incident at Livingston Health & Rehabilitation Center revealed a breakdown in communication between therapy and nursing staff that put resident safety at risk, according to a November federal inspection.
Resident #16 required a mechanical lift for all transfers due to her weakness. But on August 28, a physical therapist moved her from bed to wheelchair using a sliding board and failed to leave the lift sling underneath her that would allow staff to safely return her to bed.
When nursing staff found the resident in her wheelchair hours later, they faced an impossible choice. The woman was too weak to stand, but no lift sling was available.
"Nurse and [staff member P] attempted to place a sling under her but she was too weak so they had to do a stand pivot transfer with gait belt to get her safely back to bed with 3 staff members present," one staff member wrote in a statement after the incident.
The manual transfer went badly. At 10:40 a.m., a nurse documented that the resident reported "there was an accident." The assessment revealed "soft tissue swelling just below left knee. Area is the size of a tennis ball."
The facility reported the injury to state officials as a hematoma of unknown origin, though their own investigation determined it "likely occurred as a result of a difficult resident transfer from the wheelchair to bed."
Staff member B, interviewed during the federal inspection, confirmed that resident #16 "was supposed to be transferred only using a hoyer lift." The staff member explained that physical therapy "had transferred resident #16 earlier in the day from her bed to her wheelchair using a slider board and did not leave a hoyer lift sling underneath her."
"The CNAs should have been told how to transfer the resident," said staff member L during the inspection interview.
The communication breakdown reflected deeper systemic problems at the facility. Staff member O told inspectors that nursing had classified the resident as requiring mechanical lift transfers "due to weakness," while therapy was using sliding boards for transfers.
"She believed there was a system problem or communication problem, as the therapists were getting pulled into resident rooms frequently by CNAs to relay a transfer status or instruct staff on transferring residents," inspectors noted.
The resident's care plan, dated May 22, still showed she could perform transfers with one-person assistance. No updates reflected her deteriorating condition or the change to mechanical lift requirements.
Staff member B told inspectors that "physical therapy should have ensured the staff could safely transfer resident #16 back into her bed" after completing the therapy session.
When inspectors requested recent therapy recommendation forms for the resident, they received two documents from June. Neither addressed her transfer status or ability.
The incident highlighted how easily safety protocols can break down when departments fail to communicate. A routine therapy session became dangerous when the therapist departed without ensuring nursing staff could safely complete the resident's care.
The resident's injury was preventable. Her care team knew she was too weak for manual transfers. The mechanical lift equipment was available. But a missing sling and poor communication left nursing staff attempting a three-person manual transfer of a woman who couldn't support her own weight.
The tennis ball-sized hematoma served as physical evidence of what happens when safety systems fail. The resident's leg bore the consequences of institutional dysfunction that put convenience ahead of proper protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Livingston Health & Rehabilitation Center from 2025-11-18 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
LIVINGSTON HEALTH & REHABILITATION CENTER in LIVINGSTON, MT was cited for abuse-related violations during a health inspection on November 18, 2025.
Resident #16 required a mechanical lift for all transfers due to her weakness.
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.