8 CMS Surveys
Inspection Report — Nov 18, 2025
Renewal
Date: Nov 18, 2025
Visit Reason
Routine renewal inspection of Livingston Health & Rehabilitation Center to assess compliance with health and safety regulations.
Findings
The facility failed to provide adequate pain and anxiety management for a hospice resident, timely report investigative findings, complete thorough investigations and documentation, update care plans, ensure professional standards in medication administration, and safely transfer a resident, resulting in multiple deficiencies affecting resident care and safety.
Deficiencies (6)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: licensed nursing staff neglected to provide necessary pain and anxiety management for a hospice resident, resulting in discomfort due to missed medication doses and lack of assessment.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: facility staff failed to report investigative findings for reportable events within required timeframes, submitting reports two days late on two occasions.
F 0610 Respond appropriately to all alleged violations: facility staff failed to complete a thorough investigation and corrective action following neglect allegations related to bowel and bladder care and failed to document physician ordered medication and treatment orders for multiple residents.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: facility failed to update a resident's care plan to reflect current transfer ability, increasing risk of injury during transfers.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: a facility nurse failed to ensure medication administration and documentation met professional standards for 23 residents, with incomplete or inaccurate records and inconsistent medication delivery.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: facility failed to ensure a resident was transferred safely, resulting in injury due to use of an incorrect transfer method and lack of communication regarding transfer status.
Report Facts
Residents sampled for pain management: 2
Residents sampled for injuries: 2
Residents sampled for medication and treatment documentation: 24
Residents affected by medication documentation issues: 23
Residents affected by neglect allegations: 5
Residents affected by incomplete medication and treatment records: 21
Medication doses missed for resident #116: 1
Medication doses administered to resident #116 on 9/25/25: 4
Medication doses administered to resident #116 on 9/26/25: 1
Medication administration times for resident #20: 1
Medication administration times for resident #13: 1
Inspection Report — Jun 5, 2025
Date: Jun 5, 2025
Visit Reason
The survey was conducted to assess the facility's compliance with safety standards and to ensure a safe environment for residents.
Findings
The facility failed to provide a safe shower environment due to the placement of the emergency pull string station being inaccessible to a resident using the shower chair. The facility acknowledged the issue and planned to extend the pull string cord to improve safety.
Deficiencies (1)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide a safe shower environment because the emergency pull string station was located too far from a resident seated in the shower chair, creating a safety hazard.
Report Facts
Residents sampled: 24
Resident affected: 1
Inspection Report — Jun 5, 2025
Renewal
Date: Jun 5, 2025
Visit Reason
The survey was conducted as a routine renewal inspection to assess compliance with licensing requirements and ensure resident safety and care quality.
Findings
The facility was cited for multiple deficiencies including failure to maintain resident privacy, inadequate cleaning and sanitation, incomplete and unclear physician orders for wound care, improper medication storage with expired stock, lapses in infection prevention practices including PPE use and hand hygiene, lack of legionella prevention measures, and failure to ensure immunizations were reviewed and administered.
Deficiencies (6)
F 0583 Keep residents' personal and medical records private and confidential: the facility failed to provide resident privacy during personal care for one resident, leaving the resident exposed to public view.
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: the facility failed to maintain a clean and safe environment in a resident's living area, with multiple liquid spills, dirt, dust, and debris present.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to ensure physician orders were complete, current, and followed for two residents with wounds, potentially impacting wound healing.
F 0761 Ensure drugs and biologicals used in the facility are labeled and stored properly: the facility failed to dispose of expired stock medications, placing residents at risk of receiving expired drugs.
F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure proper use of personal protective equipment and hand hygiene during resident care, failed to document legionella prevention measures, increasing infection risk.
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: the facility failed to ensure immunizations were reviewed and administered for one resident, increasing infection risk.
Report Facts
Residents sampled: 24
Residents affected by privacy issue: 1
Residents affected by cleaning issue: 1
Residents affected by wound care orders: 2
Expired medications found: 9
Residents affected by infection control issues: 9
Months missing legionella temperature logs: 5
Residents sampled for immunization review: 24
Residents missing pneumonia vaccine: 1
Inspection Report — Dec 31, 2024
Renewal
Date: Dec 31, 2024
Visit Reason
The survey was a renewal inspection of Livingston Health & Rehabilitation Center in Livingston, MT.
Findings
The facility failed to maintain adequate licensed nursing coverage, timely update care plans, manage resident pain effectively, ensure safe discharge planning, provide sufficient dietary staffing, and maintain sanitary kitchen conditions. These deficiencies affected multiple residents and increased risks of harm.
Deficiencies (8)
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility failed to ensure sufficient nursing staff were available, leaving 44 residents without licensed nurse coverage for over 1.5 hours on 12/26/24 when the LPN and CNA left the facility together during the night shift.
F 0610 Respond appropriately to all alleged violations: the facility failed to complete a thorough investigation and implement interventions to prevent further resident-to-resident abuse involving residents #3, #21, #71, and #83, including failure to keep residents separated as ordered.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: care plans for residents #3, #71, and #83 were incomplete or not updated timely to reflect changes in condition, altercations, diet orders, or medication use.
F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to identify and intervene timely for severe weight loss in residents #47 and #71, delayed diet changes, and did not monitor effectiveness of interventions, resulting in continued weight loss.
F 0697 Provide safe, appropriate pain management for a resident who requires such services: the facility failed to adequately assess and manage pain for resident #71, who was observed crying out in pain for extended periods, had inconsistent pain medication administration, and was rarely repositioned due to pain.
F 0624 Prepare residents for a safe transfer or discharge from the nursing home: the facility failed to ensure resident #47 was properly prepared and oriented for discharge, including failure to send all medications home and incomplete discharge planning documentation.
F 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service: the dietary department was severely understaffed, causing late meal service, resident meal preferences not being met, and inadequate cleaning and food preparation.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to maintain sanitary kitchen and dietary storage conditions, including unlabeled and expired food items, dirty equipment, and inadequate cleaning, increasing risk of foodborne illness.
Report Facts
Residents in facility: 44
Weight loss (pounds): 26
Weight loss (%): 17
Weight loss (%): 12.1
Weight loss (%): 6.2
Medications: 21
Dietary staff scheduled: 4
Dietary staff scheduled: 2
Food temperature checks: 38
Inspection Report — Jul 3, 2024
Renewal
Date: Jul 3, 2024
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with licensing requirements and ensure resident safety and care quality.
Findings
The facility had multiple deficiencies including failure to obtain medication self-administration orders, failure to timely report major injuries, incomplete investigations of resident-to-resident verbal abuse, lack of baseline care plan summaries for residents, inadequate pressure ulcer care, medication errors exceeding 5%, insufficient dietary staffing causing late meal service, and improper management of the communal resident personal food refrigerator.
Deficiencies (8)
F 0554 Allow residents to self-administer drugs if determined clinically appropriate: the facility failed to obtain a medication self-administration physician's order before leaving medications at a resident's bedside.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report a major injury of unknown cause to the State Survey Agency.
F 0610 Respond appropriately to all alleged violations: the facility failed to provide evidence of investigation and follow-up for resident-to-resident verbal abuse incidents.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to provide residents or their representatives with a summary of their baseline care plan.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to identify if a wound was unavoidable and failed to ensure proper wound care treatments were performed as ordered.
F 0759 Ensure medication error rates are not 5 percent or greater: the facility had a 15% medication error rate due to incorrect dosing and failure to prime insulin pens before administration.
F 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service: the facility failed to sufficiently staff the dietary department, resulting in late meal service and unmet resident preferences.
F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors: the facility failed to ensure proper management and monitoring of the communal resident personal food refrigerator and freezer.
Report Facts
Residents sampled for medication administration: 4
Medication error rate (%): 15
Wound care treatments missed: 18
Wound care opportunities: 23
Residents sampled for baseline care planning: 6
Residents sampled for injuries: 2
Residents sampled for verbal abuse allegations: 25
Dietary staff on site: 5
Wound stage: 2
Food and Nutrition Services Manager: 1
Food and Nutrition Services staff: 8
Inspection Report — Jul 3, 2024
Date: Jul 3, 2024
Visit Reason
The survey was conducted to investigate allegations of resident-to-resident verbal abuse incidents reported to the State Survey Agency.
Findings
The facility failed to provide evidence of reporting, investigation, and follow-up actions for two resident-to-resident verbal abuse incidents occurring on 12/4/23 and 1/16/24. No documentation or reports of findings were submitted by the end of the survey period.
Deficiencies (1)
F 0610 Respond appropriately to all alleged violations: the facility did not provide evidence of investigation or follow-up for two resident-to-resident verbal abuse incidents reported on 12/4/23 and 1/16/24.
Report Facts
Residents sampled: 25
Residents involved: 4
Inspection Report — Jun 8, 2023
Renewal
Date: Jun 8, 2023
Visit Reason
The survey was conducted as a renewal inspection to assess compliance with licensing requirements and ensure resident safety and care quality.
Findings
The facility failed to maintain a clean and hazard-free environment in resident rooms and common areas, ensure accurate resident assessments, consistently provide activities of daily living care, timely wound care, appropriate pain management, complete medical records, and an effective infection prevention and control program.
Deficiencies (7)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: the facility failed to keep resident #4's bathroom and common areas clean, with soiled toilets, sinks, and dirty dining room windows.
F 0641 Ensure each resident receives an accurate assessment: the facility failed to maintain accurate MDS weight data for resident #85, with discrepancies between medical records and MDS reports, and MDS modifications were not completed by survey end.
F 0677 Provide care and assistance to perform activities of daily living: the facility failed to consistently remove facial hair for resident #31, causing embarrassment.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to provide timely wound care orders for resident #24, with a delay between wound observation and physician orders.
F 0697 Provide safe, appropriate pain management: the facility failed to provide timely pain medication to residents #31 and #90 according to professional standards and resident preferences.
F 0842 Safeguard resident-identifiable information and maintain medical records: the facility failed to maintain complete physician progress notes for residents #14, 24, 29, 31, and 85.
F 0880 Provide and implement an infection prevention and control program: the facility failed to maintain infection control logs, committee meeting minutes, communicable disease tracking, and legionellosis prevention practices.
Report Facts
Residents affected: 6
Residents affected: 5
Residents affected: 2
Residents affected: 4
Infection control log missing months: 7
Pain rating scale: 8
Pain rating scale: 7
Inspection Report — Jun 8, 2023
Renewal
Date: Jun 8, 2023
Visit Reason
Routine renewal inspection of Livingston Health & Rehabilitation Center to assess compliance with health and safety regulations.
Findings
The facility failed to maintain a clean and hazard-free environment in resident rooms and common areas, did not thoroughly investigate all alleged wound care neglect cases, and failed to assess a hypotensive resident who later fell and sustained a major injury.
Deficiencies (3)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely: the facility failed to keep a resident's bathroom and common areas clean, with soiled toilets, sinks, and dirty dining room windows.
F 0610 Respond appropriately to all alleged violations: the facility failed to thoroughly investigate wound care neglect allegations for one resident, missing documentation for a second resident with worsening pressure wounds.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to assess a hypotensive resident with dizziness complaints who later fell and sustained a major injury.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Sampled residents: 6
Sampled residents: 2
Sampled residents: 4
Blood pressure (mmHg): 74.48
Blood pressure (mmHg): 68.43
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