Deficiencies (last 3 years)
Deficiencies (over 3 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
141% worse than Montana average
Montana average: 5.8 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Nov 18, 2025
Visit Reason
The inspection was conducted following complaints and facility-reported incidents involving neglect of care, medication administration failures, injury from improper transfer, and failure to report and investigate abuse and neglect allegations.
Complaint Details
The visit was complaint-related, triggered by allegations of neglect in pain management, failure to report and investigate abuse and neglect, medication administration errors, and unsafe resident transfers. The complaint was substantiated with multiple deficiencies found.
Findings
The facility was found to have multiple deficiencies including neglect in pain and anxiety management for a hospice resident, failure to timely report and investigate suspected abuse and neglect, incomplete medication administration and documentation for multiple residents, failure to update care plans reflecting residents' transfer abilities, and unsafe transfer practices resulting in injury.
Deficiencies (6)
Licensed nursing staff neglected to provide necessary pain and anxiety management to a hospice resident, resulting in discomfort.
Facility staff failed to timely report investigative findings for reportable events involving injuries to residents.
Facility staff failed to complete thorough investigations and corrective actions following neglect allegations and failed to document physician ordered medications and treatments for multiple residents.
Facility failed to update a resident's care plan to reflect current transfer ability, increasing risk of injury.
Facility nurse failed to ensure medication administration and documentation met professional standards for 23 residents; records did not reflect if medications were received.
Facility failed to ensure safe transfer of a resident, resulting in injury due to use of incorrect transfer method.
Report Facts
Residents sampled for pain management: 2
Residents affected by failure to report timely: 2
Residents affected by neglect allegations related to bowel and bladder care: 5
Residents with undocumented medication and treatment orders: 23
Residents sampled for injuries: 2
Residents sampled: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NF4 | Licensed Nurse | Named in findings related to neglect of pain and anxiety management, incomplete medication administration and documentation, and failure to report properly |
| Staff member B | Conducted investigations and interviews related to neglect and medication administration deficiencies | |
| Staff member A | Responsible for submitting facility's reportable incidents; involved in QAPI meetings | |
| Staff member J | Interviewed regarding abuse training and medication administration training | |
| Staff member K | Reported resident complaints about late or missed medications | |
| Staff member L | Provided information on resident transfer status and care plan updates | |
| Staff member O | Commented on transfer practices and communication issues between therapy and nursing staff | |
| Staff member E | Received report from NF4 and noted lack of headache report and incomplete charting |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, safety, wound care, medication management, infection control, and immunization policies at Livingston Health & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to maintain resident privacy during personal care, inadequate cleanliness and safety of the living environment, incomplete and unclear physician orders for wound care, failure to dispose of expired medications, improper use of personal protective equipment and hand hygiene, lack of documentation and prevention measures for legionella, and failure to ensure immunizations were reviewed and administered.
Deficiencies (6)
Failed to provide resident privacy during personal care for 1 of 24 sampled residents.
Failed to maintain a clean and safe environment for the living area for 1 of 24 sampled residents.
Failed to ensure physician orders were completed, current, and followed by nursing staff for 2 of 24 sampled residents, potentially impacting wound healing.
Failed to dispose of expired stock medications, placing residents at risk of receiving expired medications.
Failed to ensure staff practiced appropriate use of PPE and hand hygiene, and failed to document measures to prevent legionella, increasing infection risk.
Failed to ensure immunizations were reviewed and administered for 1 of 24 sampled residents.
Report Facts
Residents sampled: 24
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 3
Expired medications: 9
Missing temperature log months: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member H | Mentioned in resident privacy and PPE deficiencies | |
| Staff member G | Mentioned in cleanliness and legionella prevention deficiencies | |
| Staff member M | Mentioned in wound care physician order deficiencies | |
| Staff member K | Mentioned in wound care and PPE deficiencies | |
| Staff member C | Mentioned in medication and PPE deficiencies | |
| Staff member D | Mentioned in PPE deficiencies | |
| Staff member B | Mentioned in PPE and immunization deficiencies | |
| Staff member E | Mentioned in PPE deficiencies | |
| Staff member I | Mentioned in hand hygiene deficiency | |
| Staff member J | Mentioned in hand hygiene deficiency | |
| Staff member L | Mentioned in legionella prevention deficiency | |
| Staff member N | Mentioned in legionella prevention deficiency |
Inspection Report
Deficiencies: 1
Date: Jun 5, 2025
Visit Reason
The inspection was conducted to ensure that the nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Findings
The facility failed to provide a safe shower environment for one resident, who felt unsafe due to a slippery tiled wall and the emergency pull string station being located too far away to reach from the shower chair. Staff acknowledged the issue and planned to extend the pull string cord for better accessibility.
Deficiencies (1)
Failed to provide a safe shower environment due to slippery tiled wall and inaccessible emergency pull string station.
Report Facts
Residents sampled: 24
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member J stated the pull cord station was unsafe and should be extended | ||
| Staff member A stated the facility would extend the pull string cord |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 9
Date: Dec 31, 2024
Visit Reason
The inspection was conducted due to complaints and allegations regarding neglect, resident-to-resident abuse, discharge planning, care plan updates, weight loss interventions, pain management, staffing shortages, and dietary service deficiencies at Livingston Health & Rehabilitation Center.
Complaint Details
The visit was complaint-related due to allegations of neglect, resident abuse, inadequate discharge planning, care plan deficiencies, weight loss, pain management issues, staffing shortages, and dietary service problems. The neglect allegation involved licensed nurse abandonment and failure to report timely. The investigation was ongoing as of the report date.
Findings
The facility failed to report alleged neglect timely, ensure licensed nurse coverage during shifts, complete thorough investigations of resident abuse, prepare residents properly for discharge, update care plans timely, address severe weight loss and pain management adequately, maintain sufficient nursing and dietary staffing, and uphold sanitary conditions in the kitchen and dietary storage areas.
Deficiencies (9)
Failed to timely report an allegation of resident neglect and left residents without licensed nurse coverage for over 1.5 hours.
Failed to complete a thorough investigation regarding resident-to-resident abuse and did not update care plans or separate residents as required.
Failed to ensure resident was prepared and oriented for discharge home, including incomplete medication discharge and lack of home health services.
Failed to update resident care plans in a timely manner for physical altercations, weight loss, and pain management.
Failed to identify and intervene timely for severe weight loss in residents, and failed to monitor effectiveness of interventions.
Failed to assess and manage resident's pain adequately, with resident crying out in pain and refusing care, and inconsistent pain medication administration.
Failed to ensure sufficient nursing staff and licensed nurse coverage on each shift, leaving residents at risk.
Failed to sufficiently staff the dietary department, causing late meal service and failure to meet resident preferences.
Failed to maintain sanitary conditions in the kitchen and dietary storage areas, including unlabeled and expired food items, unclean equipment, and inadequate cleaning schedules.
Report Facts
Residents present during inspection: 44
Weight loss percentage: 17
Weight loss percentage: 12.1
Medication administration count: 24
Dietary staffing short days: 8
Dietary staffing critically low days: 2
Sanitation checks: 38
Meal service delay: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Reported licensed nurse and CNA left facility leaving residents unattended; gathered info for state board of nursing | |
| Staff member I | Witnessed licensed nurse and CNA leaving facility; attempted to contact nurse; reported residents left unattended | |
| Staff member G | Commented on discharge planning and weight loss alert deletion | |
| Staff member K | Unaware of resident altercations; reported insufficient CNA staffing | |
| Staff member H | New MDS worker; unaware of resident altercations or care plan updates | |
| Staff member E | Reported resident #71 pain and decline; described resident's pain behaviors | |
| Staff member B | Kitchen staff; reported short staffing and unawareness of expired nutritional drinks | |
| Staff member C | Dietary staff; reported staffing needs and dented cans policy | |
| Staff member F | New kitchen staff; reported severe understaffing and lack of cleaning schedule | |
| NF2 | Reported resident #71 pain, call light delays, and staff neglect |
Inspection Report
Routine
Deficiencies: 8
Date: Jul 3, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, injury reporting, resident care planning, wound care, medication error rates, dietary staffing, and food storage management at Livingston Health & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to obtain physician orders for medication self-administration, failure to timely report major injuries, inadequate investigation of resident-to-resident verbal abuse, failure to provide baseline care plan summaries to residents, improper wound care and failure to evaluate pressure ulcers, medication errors exceeding 5%, insufficient dietary staffing causing late meal service, and improper management of the communal resident personal food refrigerator and freezer.
Deficiencies (8)
Failed to obtain a medication self-administration physician's order prior to leaving medications at a resident's bedside.
Failed to timely report a major injury that was not witnessed to the State Survey Agency.
Failed to provide evidence for reporting, investigation, and follow-up actions for resident-to-resident verbal abuse allegations.
Failed to provide residents or their representatives with a summary of their baseline care plan.
Failed to identify if a wound was unavoidable and failed to ensure proper wound care treatments were performed.
Failed to ensure medication error rates were under 5%, including errors in insulin administration and medication dosage.
Failed to sufficiently staff the dietary department, resulting in late meal service and unmet resident preferences.
Failed to ensure proper management of the communal resident personal food refrigerator and freezer, including lack of temperature logs and improper food storage.
Report Facts
Residents sampled for medication administration: 4
Residents affected: 1
Residents sampled for injuries: 2
Residents affected: 1
Residents sampled for resident-to-resident verbal abuse: 25
Residents affected: 4
Residents sampled for baseline care planning: 6
Residents affected: 3
Wound care treatments missed: 5
Wound care treatments missed: 13
Medication error rate: 15
Dietary staff total: 5
Food and Nutrition Services Manager: 1
Food and Nutrition Services staff: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member N | Named in medication self-administration order deficiency and medication administration observation | |
| Staff member A | Named in failure to report injury and failure to investigate resident-to-resident verbal abuse | |
| Staff member G | Named in baseline care plan summary deficiency | |
| Staff member H | Named in wound care deficiency and medication administration observation | |
| Staff member C | Named in wound care deficiency | |
| Staff member M | Named in dietary staffing deficiency | |
| Staff member L | Named in dietary staffing deficiency | |
| Staff member E | Named in dietary staffing and food refrigerator management deficiencies | |
| Staff member I | Named in food refrigerator management deficiency | |
| Staff member J | Named in food refrigerator management deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 3, 2024
Visit Reason
The inspection was conducted due to allegations of resident-to-resident verbal abuse incidents reported to the State Survey Agency involving four sampled residents.
Complaint Details
The complaint involved allegations of resident-to-resident verbal abuse between residents #6 and #11, and residents #20 and #32. The facility did not submit investigation reports for these incidents despite requests.
Findings
The facility failed to provide evidence of reporting, investigation, and follow-up actions for two resident-to-resident verbal abuse incidents dated 12/4/23 and 1/16/24. No documentation or report of findings was submitted by the end of the survey period.
Deficiencies (1)
Failure to provide evidence for the reporting, investigation, and follow-up actions taken to protect residents for allegations of resident-to-resident verbal abuse.
Report Facts
Residents sampled: 25
Residents involved in incidents: 4
Incident dates: 12/4/23 and 1/16/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A interviewed on 7/3/24 stated the facility did not submit reports of findings for the incidents. |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Jun 8, 2023
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for Livingston Health & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including maintaining a clean and hazard-free environment, accurate resident assessments, consistent assistance with activities of daily living, timely wound care, appropriate pain management, complete medical records, and an effective infection prevention and control program.
Deficiencies (7)
Failed to ensure a resident's room was kept clean and hazard-free, and common areas were not kept clean and homelike.
Failed to ensure a resident's MDS assessment information was complete and accurate.
Failed to consistently complete the ADL task of facial hair removal for a resident.
Failed to ensure residents received timely wound care services consistent with professional standards.
Failed to ensure pain management services were provided in accordance with professional standards and resident preferences.
Failed to maintain complete medical records, including physician progress notes, for sampled residents.
Failed to maintain a facility-wide infection prevention and control program, including missing infection control logs, lack of infection control committee meeting minutes, no established method to track communicable diseases, and inadequate legionellosis prevention practices.
Report Facts
Residents sampled: 6
Residents sampled: 4
Residents sampled: 2
Residents sampled: 5
Infection control logs missing: 7
Infection control logs incomplete: 5
Pain rating scale: 10
Pain rating: 8
Pain rating: 7
Time without pain medication: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member F | Responsible for completing MDS forms and acknowledged errors in resident #85's MDS data entry | |
| Staff member D | Provided information about facial hair removal and pain medication orders for resident #31 | |
| Staff member B | Involved in infection control program and provided information about infection control deficiencies | |
| Staff member K | Assisted with infection control and prevention program data but was not certified | |
| Staff member H | Maintenance staff responsible for water system and legionellosis prevention | |
| Staff member E | Provided information about pain management procedures | |
| Staff member C | Provided information about missing physician progress notes | |
| Staff member A | Commented on ongoing efforts to obtain medical records | |
| Staff member L | Commented on missing infection control meeting minutes | |
| Staff member NF5 | Provided information about housekeeping cleaning frequency | |
| Staff member NF7 | Provided information about cleaning of common areas |
Inspection Report
Deficiencies: 4
Date: Jun 8, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility maintenance, including investigation of alleged neglect and environmental conditions.
Findings
The facility was found to have deficiencies including failure to maintain a clean and hazard-free environment in resident rooms and common areas, inadequate investigation of wound care neglect allegations, and failure to properly assess and document a resident's hypotension and dizziness prior to a fall resulting in major injury.
Deficiencies (4)
Failed to ensure a resident's room was kept clean and hazard-free, including soiled bathroom fixtures and broken window blinds.
Failed to keep common areas, such as dining room windows, clean and homelike.
Failed to thoroughly investigate all residents possibly impacted by an allegation of wound care neglect by nursing staff.
Failed to assess a hypotensive resident with complaints of dizziness who later fell, resulting in a major injury.
Report Facts
Residents sampled: 6
Residents sampled: 2
Residents sampled: 4
Pressure wound stage: 3
Blood pressure: 74.48
Blood pressure: 68.43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NF5 | Staff member who stated resident rooms were cleaned daily | |
| NF7 | Staff member who stated common areas are cleaned daily including windows | |
| NF4 | Staff member mentioned in wound care neglect investigation | |
| NF9 | Staff member who stopped exercise and obtained low blood pressure reading for resident #86 | |
| Staff member B | Interviewed about missing documentation for investigations and resident #86's complaint |
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