Livingston Health & Rehabilitation Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on interview and record review, licensed nursing staff neglected to provide the necessary services to

a resident and assess for and treat pain and anxiety, for 1 (#116) of 2 residents sampled for pain management, and the nurse stated the resident was restless, a symptom of both anxiety and pain. The neglect of care negatively affected the resident's comfort. Findings include:During an interview on 10/21/25 at 10:30 a.m., staff member B reported she investigated a facility-reported incident involving neglect of care

on multiple residents. Staff member B reported she was concerned one resident had not received adequate pain and anxiety management from the nurse on duty on the 12-hour night shift between 6:00 p.m. on 9/25/25 and 6:00 a.m. on 9/26/25. Staff member B stated resident #116 was a hospice resident, and the resident was in end-of-life transition. The resident had been receiving as-needed lorazepam for anxiety, twice daily, and morphine several times per shift, due to restlessness and agitation. Staff member B stated

on the 12-hour night shift between 6:00 p.m. on 9/25/25 and 6:00 a.m. on 9/26/25, NF4 gave resident #116 one dose of morphine for pain at 5:59 a.m., and no lorazepam for anxiety. Staff member B stated she was able to confirm the one dose of pain medication was given by reviewing the resident's narcotic log and narcotic count.During an interview on 10/20/25 at 3:35 p.m., NF4 stated, . I gave that guy (resident #116) his morphine all night except for one dose when I couldn't get it into him because he was restless. The staff member was inconsistent in her accounting of the events and did not seem to recognize the restlessness could have been pain/anxiety related. Review of the facility's investigation documentation for the Facility-Reported Incident, dated 9/26/25, showed the following undated statement obtained from NF4 via phone: I kept up on all medication administration, even with (residents #9 and #116) being out of sorts, and combative .Review of resident #116's MAR for September 2025, showed that on 9/25/25, resident #116 received morphine at 12:56 a.m., 5:56 a.m., 9:51 a.m., and 12:59 p.m. The next dose was administered on 9/26/25 at 5:59 a.m., and it was 17 hours since the previous dose, which was the only dose given to the resident on NF4's shift.Review of resident #116's nursing progress notes, for September 2025, did not show any nursing entries for the period of 6:00 p.m. on 9/25/25 through 6:00 a.m. on 9/26/25, and why pain or anxiety medications were neglected to be given, or if the resident was assessed for why he was restless and or out of sorts.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Livingston Health & Rehabilitation Center

510 S 14th St Livingston, MT 59047

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Potential for minimal harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interview and record review, facility staff failed to report investigative findings for reportable events, within the required timeframe, for 2 (#s 16 and 123) of 2 residents sampled for injuries. Findings include:1. Review of a facility-reported incident, submitted to the State Survey Agency on 8/28/25, showed resident #16 sustained a hematoma of unknown origin to the left lower extremity. The facility's investigative findings were not reported to the State Survey Agency until 9/9/25; two days after the submission deadline.During an interview on 11/18/25 at 10:42 a.m., staff member A stated he was responsible for submitting the facility's reportable incidents through the incident reporting system. Staff member A stated

he accidentally pressed the save button instead of the send button in the reporting system and did not realize it until two days past the deadline.2. Review of a facility-reported incident, submitted to the State Survey Agency on 9/16/25, showed resident #123 sustained swelling and bruising of unknown origin to the right hand. The facility's investigative findings were not reported to the State Survey Agency until 9/25/25; two days after the submission deadline.During an interview on 11/18/25 at 10:42 a.m., staff member A stated he did not think the incident should have been reported, but the facility did report it as an unknown injury. Staff member A did not feel that the late reporting of the incident should be considered deficient practice. As with the incident above, staff member A stated he pressed the save button instead of the send button in the reporting system and did not realize it until two days past the deadline.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Livingston Health & Rehabilitation Center

510 S 14th St Livingston, MT 59047

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated, I just never thought to do that. During an interview on 10/21/25 at 1:50 p.m., staff member B stated there was an informal interdisciplinary meeting held on 10/1/25, wherein department heads received updated abuse and neglect training, but it was not a formal QAPI meeting.During an interview on 10/21/25 at 2:12 p.m., staff member C stated there had been no QAPI meeting following the incident on 9/26/25, to identify quality-deficient practices and or needed corrections related to the events and NF4.During an

interview on 10/21/25 at 3:40 p.m., staff member A stated he held a focused (adhoc) QAPI meeting after

the reportable incident, as part of the facility's plan for correction. Staff member A provided a QAPI committee minutes form with three names listed: the administrator, a corporate regional nurse, and corporate regional administrator. Staff member A stated, Everyone was there, I just haven't gathered the rest of the signatures yet. The report was dated 10/1/25. Staff member A stated the staff had all received refresher training on abuse and neglect. When the sexual abuse quiz questions were reviewed with the surveyor, staff member A stated he could have selected more relevant quiz questions, as the events with NF4 were not related to sexual abuse. Staff member A stated the questions were selected from a standard resource he had available for abuse and neglect training. During an interview on 10/24/25 at 6:33 p.m., staff member D stated he received a summary of the occurrence and investigation with NF4, by phone from staff member B, but had not been notified or invited to a QAPI meeting regarding the event. Staff member D stated he would have attended the meeting as he felt it was an important step for preventing a recurrence

in the future, to address a quality-deficient practice.Review of the facility-provided abuse and neglect training document showed a three-page document titled Abuse Prohibition Notification Policy, and it included a 4-question quiz. All questions pertained to sexual abuse of residents, no content was related to neglect of care. On 10/20/25, a request was made for evidence to show NF4 had been reported to the Montana Board of Nursing by 10/3/25, as reflected in the investigation report findings. The board notification documentation was received; however, the document was dated 10/20/25. Staff member C stated 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. On 10/20/25, a request was made for evidence of the nursing education on medication administration, and the required documentation for medications when administered. No documentation was provided before the end of the survey.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Livingston Health & Rehabilitation Center

510 S 14th St Livingston, MT 59047

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Potential for minimal harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on interview and record review, the facility failed to update a care plan to reflect a resident's ability to transfer from a wheelchair to a bed. The failure increased the resident's risk of injury during transfer for 1 (#16) of 2 residents sampled for injuries. Findings include:Review of a facility-reported incident, submitted to the State Survey Agency on 8/28/25, showed resident #16 sustained a hematoma of unknown origin to

the left lower extremity. The facility's investigation determined the injury likely occurred as a result of a difficult resident transfer from a wheelchair to a bed.During an interview on 11/17/25 2:02 p.m., staff member L stated a resident's ability to transfer and any devices required would be found in the resident's care plan.During an interview on 11/18/25 at 2:57 p.m., staff member B stated, Care plans are updated by myself, the MDS nurse, or the charge nurse . When we receive new orders from PT, it goes to a binder at

the nurses station, and we update the care plan at that time . Staff member B stated resident #16's care plan had not been updated to reflect her current transfer status and ability. Staff member B did not know why the care plan was not updated.Review of resident #16's physical therapy progress notes dated 7/23/25, showed, . Progress Report completed with review patient's performance and progression toward goals; removed standing and transfer goals as patient has too much pain and does not want to work on that anymore; Continued PT services are necessary to improve w/c mobility [sic]Review of resident #16's care plan, initiated 5/22/25, showed, The resident is able to perform all transfers with assist of one. No additional updates on resident #16's transfer status or ability were located in the care plan after 5/22/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Livingston Health & Rehabilitation Center

510 S 14th St Livingston, MT 59047

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Pain monitoring, shortness of breath monitoring, oxygen monitoring, and opioid side effect monitoring were not documented as completed. Fluorouracil cream to the left clavicle was not documented as applied per

the physician's order.19. Resident #126: Pain monitoring, psychotropic side effect monitoring, and oxygen saturation monitoring (due to rapid desaturation history) were not documented as completed.20. Resident #127: Anticoagulation side effect monitoring, pain monitoring, shortness of breath monitoring, and psychotropic side effect monitoring were not documented as completed.21. Resident #131: Psychotropic side effect monitoring and pain monitoring were not documented as completed.22. Resident #133: Pain monitoring and opioid side effect monitoring were not documented as completed. As-needed acetaminophen was not administered, although it had historically been given regularly.23. Resident #199: EBP monitoring, pain monitoring, shortness of breath monitoring, psychotropic side effect monitoring, and opioid side effect monitoring were not documented as completed.Review of the facility's investigation documentation for the Facility-Reported Incident, dated 9/26/25, showed the following undated statement obtained from NF4, via phone: I kept up on all medication administration even with (residents #9 and 116) being out of sorts and combative. in regard to the shift MAR being red, all of the work was completed. I had

a migraine, finished the work, and planned to go back into (electric health system) tonight and make sure it was all clicked off.Review of the [NAME] - Nursing Documentation information, dated August 2025, located at nursingworld.org, and accessed 10/30/25, included the following professional standard guidance for the Six Principles of Nursing Documentation which were:The American Nurses Association (ANA) has identified six principles of nursing documentation to provide guidance for producing high quality documentation (ANA, 2021). 1. Documentation Characteristics Accessible Accurate and relevant Auditable Clear, concise, comprehensive, and thoughtful Legible/readable Timely and sequential Aligned with the nursing process Retrievable on a permanent basis

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/18/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Livingston Health & Rehabilitation Center

510 S 14th St Livingston, MT 59047

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Based on interview and record review, the facility failed to ensure a resident was transferred safely and correctly, and the resident sustained an injury to the left lower extremity with swelling and bruising which the nurse documented as being tennis ball size, and it was identified the injury was caused due to staff manually transferring the resident, which was not the correct transfer status, for 1 (#16) of 2 residents sampled for injury. Findings include: Review of a facility-reported incident, submitted to the State Survey Agency on 8/28/25, showed resident #16 sustained a hematoma of unknown origin to the left lower extremity. The facility's investigation determined the injury likely occurred as a result of a difficult resident transfer from the wheelchair to bed.Review of resident #16's medical record showed on 8/28/2025 at 10:40 a.m., the nurse documented the resident stated there was an accident, and the nurse detailed the assessment of the resident's left lower extremity injury, which was soft tissue swelling just below left knee.

Area is the size of a tennis ball .Review of a written statement from staff member Q, dated 8/28/25, showed, 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 .A verbal request was made on 11/18/25 for the most recent therapy recommendation forms for resident #16. Two forms were received, dated 6/9/25 and 6/20/25. Neither form was related to resident #16's transfer status or ability to transfer.During an interview on 11/17/25 2:02 p.m., staff member L stated, I understand that PT forgot to put a sling underneath her (resident #16), 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 . During an interview on 11/18/25 at 10:40 a.m., staff member B stated resident #16 was supposed to be transferred only using a hoyer lift (full body lift). Staff member B stated the physical therapist had transferred resident #16 earlier in

the day from her bed to her wheelchair using a slider board and did not leave a hoyer lift sling underneath her, therefore, the staff had to attempt a stand and pivot transfer with the resident. Staff member B stated resident #16 was very weak, and the transfer was difficult. Staff member B stated physical therapy should have ensured the staff could safely transfer resident #16 back into her bed.During an interview on 11/18/25 at 1:41 p.m., staff member O stated resident #16 had been regressed by nursing staff to hoyer lift transfers due to weakness, and therapy was using a slider board to transfer resident #16. Staff member O stated 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.Review of resident #16's care plan, dated 5/22/25, showed the resident was able to perform all transfers with one person assisting, and there were no further updates to resident #16's transfer status in

the care plan.

Event ID:

Facility ID:

If continuation sheet