Livingston Health & Rehab: Care Quality Failures - MT
That gap, nearly three weeks, sits at the center of a November 2025 federal inspection at Livingston Health & Rehabilitation Center, a skilled nursing facility at 510 S. 14th Street in Livingston, Montana. Inspectors found the facility had failed to follow through on its own investigation findings after a September 26 incident involving a resident identified in records as NF4, and that the corrective steps it did take were incomplete, misdirected, or never fully happened.
The incident itself is referred to throughout the inspection report only by its category: a reportable event, an occurrence, an event involving NF4. The inspection does not describe what happened to NF4 in detail. What it does describe, at length, is what the facility did afterward. Or failed to do.
The facility's own investigation summary stated that NF4, a staff member, would be reported to the Montana Board of Nursing by October 3. When a surveyor requested documentation of that notification on October 20, staff member C delivered a document and said, at the time of delivery, "This was just completed today, as staff member B was not sure if Adult Protective Services was going to do the reporting to the nursing board, therefore, the facility had not reported NF4's actions to the nursing board as documented in the investigation summary."
In other words: the facility had written a deadline into its own records, missed it by more than two weeks, and only completed the filing when inspectors came looking.
Staff member C's explanation was that someone else might have handled it. Nobody had.
The facility's response to the incident also included abuse and neglect training for staff. On October 1, department heads gathered for what staff member B described as an informal interdisciplinary meeting. Staff member B told inspectors the session covered updated abuse and neglect training. Staff member C confirmed there had been no formal QAPI meeting following the September 26 incident, the kind of structured quality review designed to identify what went wrong and how to prevent it from happening again.
Then the administrator, identified as staff member A, told inspectors something different. He said he had held a focused, ad hoc QAPI meeting after the incident as part of the facility's correction plan. He produced a committee minutes form with three names on it: himself, a corporate regional nurse, and a corporate regional administrator. When asked about the rest of the signatures, staff member A said, "Everyone was there, I just haven't gathered the rest of the signatures yet." The form was dated October 1.
Staff member D, another person who worked at the facility, told inspectors on October 24 that he had received a phone summary of the NF4 incident from staff member B, but had never been notified about or invited to a QAPI meeting. He said he would have attended. "He felt it was an important step for preventing a recurrence in the future, to address a quality-deficient practice," the inspection report notes.
So the administrator said everyone was there. A staff member who expected to be there said he was never called.
The training itself had its own problem. The abuse and neglect refresher given to staff was a three-page document titled "Abuse Prohibition Notification Policy," accompanied by a four-question quiz. Every question on the quiz was about sexual abuse of residents. None of the content addressed neglect of care.
The incident involving NF4 was not a sexual abuse case.
When a surveyor reviewed the quiz questions with staff member A, the administrator acknowledged the mismatch. He said "he could have selected more relevant quiz questions, as the events with NF4 were not related to sexual abuse." He explained the questions had been pulled from a standard resource he had available for abuse and neglect training.
The facility had gathered its staff, administered a quiz, and documented the training. The quiz measured knowledge of something that had nothing to do with what had just happened.
There was a fourth problem, quieter than the others. On October 20, inspectors requested documentation of nursing education on medication administration and required medication documentation. Nothing was provided before the survey closed on November 18.
The inspection was filed under F0610, which addresses a facility's obligations to investigate and respond to allegations or incidents of abuse, neglect, and exploitation, and to report findings to the appropriate authorities. The level of harm was listed as minimal harm or potential for actual harm. Some residents were affected.
That classification may accurately reflect what inspectors could measure. It does not capture what the record shows about how this facility handled the aftermath of a serious incident: a reporting deadline it set for itself and missed, a corrective meeting that at least one key participant knew nothing about, training materials that addressed the wrong category of harm entirely, and documentation that materialized only when someone came asking for it.
Staff member A, asked about the QAPI meeting, said everyone was there. He just hadn't gotten around to collecting the signatures.
Staff member B, asked why the nursing board notification had been delayed, said she wasn't sure who was supposed to do it.
Staff member C delivered the completed nursing board notification the same afternoon inspectors requested it, with no apparent acknowledgment that the facility's own written record had promised it seventeen days earlier.
What happened to NF4 on September 26 remains, in the public record, a category. A reportable event. An occurrence. The inspection report does not describe it further. What it describes instead is a facility that wrote down what it would do, then did not do it, and in some cases did something else entirely, and in at least one case did nothing at all until the question was asked out loud.
The resident at the center of it, NF4, appears in the report as a designation, not a person. Whether they knew what promises the facility made about accountability, or whether those promises were kept, the inspection record does not say.
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: August 4, 2026 · Our methodology
LIVINGSTON HEALTH & REHABILITATION CENTER in LIVINGSTON, MT was cited for violations during a health inspection on November 18, 2025.
14th Street in Livingston, Montana.
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.