Livingston Health & Rehab: Safety Hazard Failures - MT
The August incident at Livingston Health & Rehabilitation Center occurred when physical therapy staff left the resident in her wheelchair without the sling needed for her prescribed hoyer lift transfers. Nursing assistants then attempted a stand-and-pivot transfer with three staff members present, causing the injury to her left lower extremity.
"Resident was found in her wheelchair with no sling under her and wanted to be transferred to bed," staff member Q wrote in a statement dated August 28. "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."
The resident, identified as #16 in the inspection report, had been downgraded to hoyer lift transfers due to weakness. But therapy staff continued using a slider board for transfers, creating confusion about proper protocols.
Staff member B told inspectors the physical therapist had moved the resident from bed to wheelchair earlier that day using the slider board but failed to leave the hoyer lift sling underneath her. "The staff had to attempt a stand and pivot transfer with the resident," the staff member explained. "Resident #16 was very weak, and the transfer was difficult."
The nurse documented the injury at 10:40 a.m. on August 28, noting "soft tissue swelling just below left knee" that measured "the size of a tennis ball." The resident told the nurse "there was an accident."
Staff member L described the miscommunication during a November interview: "I understand that PT forgot to put a sling underneath her, and the CNAs had trouble getting her back to bed with pivot and lift. The CNAs should have been told how to transfer the resident."
The facility's own investigation determined the injury "likely occurred as a result of a difficult resident transfer from the wheelchair to bed." The incident was reported to state authorities on August 28.
Staff member O identified systemic problems with transfer protocols. "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," according to the inspection report.
The resident's care plan, last updated May 22, still listed her as "able to perform all transfers with one person assisting." No updates reflected her regression to requiring mechanical lift assistance.
When inspectors requested therapy recommendation forms for the resident, they received two documents from June that contained no information about her transfer status or ability.
The communication breakdown between therapy and nursing staff left certified nursing assistants without clear guidance on safe transfer methods. Physical therapy continued using equipment the resident could no longer safely use, while nursing staff had downgraded her to mechanical assistance.
Staff member B emphasized that "physical therapy should have ensured the staff could safely transfer resident #16 back into her bed."
The facility reported the hematoma as being of "unknown origin" initially, though their investigation concluded it resulted from the improper transfer attempt. The injury required no treatment beyond monitoring, but highlighted gaps in interdisciplinary communication about resident care needs.
The inspection found the facility failed to ensure safe transfers and adequate supervision to prevent accidents. The resident's injury occurred because staff attempted a transfer method she was too weak to safely complete, despite established protocols requiring mechanical assistance.
Federal inspectors cited the facility for failing to maintain an accident-free environment and provide proper supervision during resident transfers.
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 violations during a health inspection on November 18, 2025.
Nursing assistants then attempted a stand-and-pivot transfer with three staff members present, causing the injury to her left lower extremity.
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.