Livingston Health & Rehab: Care Plan Delays - MT
The August incident occurred when staff discovered resident #16 in her wheelchair without the sling needed for her prescribed hoyer lift transfer. Rather than retrieve the proper equipment, three staff members attempted a stand-and-pivot transfer using only a gait belt.
The resident was "too weak" for the manual transfer, according to a written statement from staff member Q. The difficult transfer left the resident with soft tissue swelling "just below left knee" that the nurse documented as "the size of a tennis ball."
Staff member B told inspectors that resident #16 "was supposed to be transferred only using a hoyer lift." The problem began earlier that day when a physical therapist transferred the resident from bed to wheelchair using a slider board but failed to leave the hoyer lift sling underneath her.
"The CNAs had trouble getting her back to bed with pivot and lift," staff member L explained to inspectors. "The CNAs should have been told how to transfer the resident."
The facility's own investigation determined the hematoma "likely occurred as a result of a difficult resident transfer from the wheelchair to bed." Yet the resident's care plan, last updated in May, still indicated she could perform transfers with just one person assisting.
Staff member O identified a broader communication breakdown, telling inspectors there was "a system problem" because therapists were "getting pulled into resident rooms frequently by CNAs to relay a transfer status or instruct staff on transferring residents."
The nursing staff had already "regressed" resident #16 to hoyer lift transfers due to her weakness, but therapy continued using slider boards. This disconnect left nursing assistants without clear guidance on how to safely move the resident.
Staff member B said physical therapy "should have ensured the staff could safely transfer resident #16 back into her bed." Instead, the therapist left the resident stranded in her wheelchair without the mechanical assistance she required.
The resident told the nurse on August 28 "there was an accident" when asked about the swelling on her leg. The injury was significant enough that the facility reported it to state surveyors as a hematoma of unknown origin.
Federal inspectors found the facility failed to provide adequate supervision to prevent the accident. The violation affected few residents but created minimal harm or potential for actual harm.
The case illustrates how communication failures between departments can directly injure vulnerable residents. When the physical therapist used one transfer method but nursing staff expected another, resident #16 paid the price with a painful leg injury.
Her care plan remained outdated for months, showing she could transfer with minimal assistance even as staff had determined she needed full mechanical lifting due to weakness. The outdated documentation contributed to the confusion about her actual capabilities.
Three staff members participated in the improper transfer, yet none questioned whether manually moving such a weak resident was appropriate. The facility's own investigation acknowledged the transfer was "difficult," but the injury had already occurred.
Resident #16's hematoma serves as a visible reminder of what happens when nursing homes fail to maintain consistent transfer protocols across departments.
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.
The August incident occurred when staff discovered resident #16 in her wheelchair without the sling needed for her prescribed hoyer lift transfer.
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.