Livingston Health & Rehabilitation: Abuse Prevention - MT
The resident sustained a tennis ball-sized hematoma on her left leg.
Staff member B told inspectors on November 18 that resident 16 "was supposed to be transferred only using a hoyer lift." But the physical therapist had moved her from bed to wheelchair earlier that day using a slider board and failed to leave the hoyer sling underneath her.
When nursing staff found the resident in her wheelchair that evening, they couldn't get the sling under her. She was too weak.
Staff member Q wrote in an incident report: "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 manual transfer injured her.
At 10:40 a.m. on August 28, a nurse documented the resident's complaint: "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 hematoma to state authorities the same day, acknowledging in its investigation that "the injury likely occurred as a result of a difficult resident transfer from the wheelchair to bed."
Staff member L told inspectors during a November 17 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 confusion stemmed from conflicting transfer methods. Nursing staff had designated the resident for hoyer lift transfers "due to weakness," according to staff member O. But therapy was using a slider board.
"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 wrote about staff member O's November 18 interview.
The resident's care plan, last updated May 22, showed she "was able to perform all transfers with one person assisting." No updates reflected her declining condition or the change to mechanical lift requirements.
Staff member B described the August incident as particularly difficult. The resident "was very weak, and the transfer was difficult," she told inspectors. She said "physical therapy should have ensured the staff could safely transfer resident 16 back into her bed."
When inspectors requested the most recent therapy recommendation forms for resident 16 on November 18, they received two documents dated June 9 and June 20. Neither addressed her transfer status or ability.
The incident revealed a breakdown in communication between departments. Physical therapy was using one transfer method while nursing had implemented stricter requirements due to the resident's weakness. No system existed to ensure staff knew which method to use when the resident needed to return to bed.
Three staff members were present for the manual transfer that injured the resident. All knew she was too weak for the stand-and-pivot method they attempted. But without the proper equipment left by therapy, they had no safe alternative to get her back to bed.
The facility's investigation concluded the hematoma resulted from the "difficult resident transfer." The tennis ball-sized swelling documented by the nurse provided physical evidence of the harm caused when staff used the wrong transfer technique on a resident too weak to safely support her own weight.
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.
The resident sustained a tennis ball-sized hematoma on her left leg.
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.