Livingston Health & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain a water management program for the prevention of waterborne pathogens in accordance with CDC guidance for 1 (#6) of 20 sampled and supplemental residents. Environmental testing identified Legionella bacteria within the facility's water system after resident #6 was diagnosed with Legionnaires' disease. The facility's failure to implement and maintain its water management program placed all residents at increased risk for exposure to waterborne pathogens. During the survey, it was found that the facility had previously identified, investigated, and corrected the non-compliance for the water management system, resulting in findings of Past Non-Compliance.

Inspectors wroteBased on interview, observation, and taste testing of food served by the facility, the facility failed to provide food at a palatable and appetizing temperature for 5 (#s 14, 28, 40, 48, and 52) of 20 sampled and supplemental residents. This deficient practice affected the residents' nutrition, weight management, and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of the COVID-19 vaccination status (received or refused) for one staff member (staff member M) of 2 sampled staff for COVID-19 vaccination status.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from neglect for a resident who was dependent upon staff for incontinence care, resulting in the resident not receiving the necessary incontinence care for an extended period. The failure placed the resident at risk for skin breakdown, infection, pain, discomfort, loss of dignity, and psychosocial distress, for 1 (#18) of 7 residents sampled for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure thorough investigations of alleged abuse and neglect were completed for 2 (#s 10 and 50) of 7 residents sampled for abuse. This deficient practice could place other residents at risk for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to notify residents and the residents' representatives in writing, of the reason for the transfer and the required bed hold information for 3 (#s 3, 6, and 56) of 20 sampled and supplemental residents.

Inspectors wroteBased on interview and record review, the facility failed to complete a baseline care plan which provided instructions needed to provide personalized resident-centered care for 1 (#28) of 20 sampled and supplemental residents. The failure to have a baseline care plan placed the resident at risk of not being provided care to meet their basic needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure prescribed psychotropic medications were administered as ordered for 1 (#51) of 6 residents sampled for medication administration by failing to obtain prescribed medications and failing to notify the physician when the medications could not be administered. The failures placed the resident at risk for increased mental health symptoms and other adverse clinical outcomes associated with interruption of prescribed psychotropic medication therapy.

Inspectors wroteBased on interview and record review, the facility staff failed to complete a thorough investigation and comprehensive corrective action, following a facility-reported event involving neglect allegations related to bowel and bladder care of 5 dependent residents (#s 12, 32, 33, 42 and 112); and staff failed to document physician ordered medication and treatment orders for 23 residents (#s 6, 9,12, 13, 15, 20, 22, 23, 27, 32, 33, 112, 114, 116, 118, 121, 123, 124, 126, 127, 131, 133, and 199) of 24 sampled residents. Findings Include: Review of a Facility-Reported Incident, submitted to the State Survey Agency on 9/26/25, included two separate incidents involving neglect of resident care. The first event occurred on the 12-hour night shift beginning at 6:00 p.m. on 9/19/25. [...]

Inspectors wroteBased on interview and record review, a facility nurse failed to ensure nursing services were provided in accordance with professional standards for medication administration and documentation for 23 (#s 6, 9, 12, 13, 15, 20, 22, 23, 27, 32, 33, 112, 114, 116, 118, 121, 123, 124, 126, 127, 131, 133, and 199) residents, of 24 sampled, and the residents medical records did not reflect if the residents received their ordered medications.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff practiced appropriate use of personal protective equipment (PPE), during care of residents on enhanced barrier precautions (EBP) for 4 (#s 20, 43, 45, and 199); failed to ensure staff practiced appropriate use of PPE during the care of a resident on contact precautions for 2 (#s 6 and 7); failed to ensure appropriate hand hygiene was performed while providing meal assistance in the dining room for 3 (#s 13, 32, and 42) of 24 sampled residents. The facility also failed to document measures taken to prevent legionella. These deficient practices increased the risk of infections within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired stock medication. This deficient practice placed the residents at risk of receiving expired stock medications.

Inspectors wroteBased on observation and interview, the facility failed to provide resident privacy during personal care for 1 (#20) of 24 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and safe environment for the living area for 1 (#27) of 24 sampled residents. This deficient practice left the resident feeling frustrated and unable to independently move his bedside table in his room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were completed, current, and followed by nursing staff, for 2 (#s 43 and 199) of 24 sampled residents. This had the potential to negatively impact a resident's wound healing.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe shower environment for 1 (#7) of 24 sampled residents. This failure resulted in a resident feeling unsafe while showering in the shower room.

Inspectors wroteBased on interview and record review, the facility failed to ensure immunizations were reviewed and administered for 1 (#100) of 24 sampled residents, increasing the risk of infections of the residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify resident's with weight loss, implement weight loss interventions timely, and failed to monitor the effectiveness of weight loss interventions, for 2 (#s 47 & 71) of 11 sampled residents. Resident #47 had a severe 17% weight loss in 42 days, and #71 had a severe weight loss of 12.1% of her body weight in 63 days.

Inspectors wroteBased on observation, interview, and record review, the facility nursing staff failed to assess and manage a resident's pain, and proceeded with the provision of care when the resident voiced pain, and showed other indicators of pain, to include crying and calling out and in pain, and refusing ADL care, for 1 (#71) of 11 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient nursing staff were available for the provision of resident care and that a licensed nurse was always available. This deficient practice had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to sufficiently staff the dietary department with the necessary staff to carry out the normal functions of the department. This deficient practice caused meals to be served late and the department was not meeting resident preferences.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure sanitary conditions were maintained throughout the kitchen, and the dietary storage areas; failed to ensure kitchen staff labeled and dated food in the coolers; and, failed to maintain a clean (dietary/kitchen) environment. This deficient practice increased the risk for the development of foodborne illnesses and deficient practices related to sanitary conditions, for all residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident neglect within 24 hours of the incident, and the designated licensed nurse left the facility during his shift when he was the only nurse on duty at the time, leaving all 44 residents at risk for adverse events. This deficient practice increased the risk of harm or a negative outcome for any resident at the facility, due to the lack of a nursing availability.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a thorough investigation regarding resident-to-resident abuse, including addressing or identifying interventions to stop further abuse, for 4 (#s 3, 21, 71 and 83) of 11 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to update resident care plans in a timely manner for 3 (#s 3, 71, and 83) of 11 residents sampled for physical altercations, weight loss, and pain management.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was prepared and oriented for discharge home, for 1 (#47) of 1 sampled resident. Findings Include: During an interview on 12/30/24 at 4:49 p.m., staff member G said she would expect discharge planning to be completed prior to the day, or even the day before, a discharge. Staff member G said she had seen the discharge note asking about home health for #47 at the time of discharge, but not prior to discharge. Staff member G was unaware if a referral to a home health agency had been completed. Staff member G said the social service staff person would usually be responsible for discharge planning, but the staff member was out of the facility at the time of #47's discharge, and the BOM was helping with discharges. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide evidence for the reporting, investigation, and follow up actions taken to protect residents, for an allegation of a resident-to-resident verbal abuse to the State Survey Agency for 4 (#s 6, 11, 20 and 32) of 25 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rates were under 5%, which affected 2 (#s 1 and 8) of 4 residents sampled for medication administration. The calculated medication error rate was 15%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to sufficiently staff the dietary department with the necessary staff to carry out the normal functions of the department. This deficient practice had the potential to affect all residents served meals by the dietary department, by causing meals to be served late, and not meeting resident preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a medication self-administration physician's order prior to leaving medications at a resident's bedside, for 1 (#4) of 4 residents sampled for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to report a major injury that was not witnessed, and there was not a reliable source for the cause of the injury, to the State Survey Agency, for 1 (#6) of 2 residents sampled for injuries.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide residents or their representatives with a summary of their baseline care plan for 3 (#'s 14, 144, and 145) of 6 residents sampled for baseline care planning.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify if a wound was unavoidable or not, and the facility failed to ensure proper wound care treatments were performed for 1 (#8) of 1 sampled resident for wound care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper management of the communal resident personal food refrigerator and freezer.