Livingston Health & Rehab: Abuse Response Failures - MT
The August incident at Livingston Health & Rehabilitation Center revealed a dangerous breakdown in communication between therapy and nursing staff that left resident #16 with a hematoma below her left knee.
On August 28, the resident told a nurse there had been "an accident." The nurse documented soft tissue swelling "just below left knee" that was "the size of a tennis ball."
Staff member Q wrote in a statement that day: "Resident was found in her wheelchair with no sling under her and wanted to be transferred to bed. 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."
The resident was supposed to be transferred only using a Hoyer lift, a mechanical device that safely moves patients who cannot support their own weight. But the physical therapist had moved her from bed to wheelchair earlier that day using a slider board and failed to leave the necessary sling underneath her.
"The CNAs should have been told how to transfer the resident," staff member L told inspectors on November 17.
Staff member B explained the impossible situation nursing assistants faced that morning. The physical therapist "did not leave a hoyer lift sling underneath her, therefore, the staff had to attempt a stand and pivot transfer with the resident." The resident was "very weak, and the transfer was difficult."
Nobody had updated the resident's care plan since May 22, which still indicated she could perform transfers with just one person assisting. But nursing staff had actually regressed her to requiring full mechanical lift assistance due to her increasing weakness.
"Physical therapy should have ensured the staff could safely transfer resident #16 back into her bed," staff member B said.
The confusion stemmed from competing transfer methods. While nursing staff recognized the resident's declining strength and required Hoyer lift transfers, therapy continued using slider boards. Staff member O described "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."
When inspectors requested the most recent therapy recommendations for resident #16, they received two forms dated June 9 and June 20. Neither addressed her transfer status or ability.
The facility reported the incident to state surveyors the same day it occurred, acknowledging their investigation determined "the injury likely occurred as a result of a difficult resident transfer from the wheelchair to bed."
Three staff members were present for the August 28 transfer attempt, yet none could safely move the resident without causing injury. The manual "stand pivot transfer with gait belt" they attempted requires patients to bear weight on their legs and maintain balance — abilities resident #16 had already lost.
Staff member O's observation about therapists being "pulled into resident rooms frequently" suggests this communication breakdown affected multiple residents. The facility's therapy and nursing departments operated with conflicting protocols, leaving vulnerable residents caught between incompatible care approaches.
Federal inspectors cited the facility for failing to ensure safe transfers and adequate supervision to prevent accidents. The violation affected few residents but caused minimal harm or potential for actual harm.
The resident's injury could have been prevented if the physical therapist had either left the Hoyer sling in place or communicated the change in transfer method to nursing staff. Instead, three workers struggled to move a weak resident manually, causing the exact type of injury mechanical lifts are designed to prevent.
The tennis ball-sized hematoma served as visible evidence of what happens when safety protocols break down and staff are forced to improvise with patients they cannot safely handle.
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.
But the physical therapist had moved her from bed to wheelchair earlier that day using a slider board and failed to leave the necessary sling underneath her.
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.