Livingston Manor Care Center

In the surveyor’s words

From the most serious findings on record at Livingston Manor Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 26, 2024

  Based on interview and record review, facility staff failed to protect two sampled residents (Resident #2 and Resident #3) from resident to resident sexual abuse. Resident #1 was identified to have sexual behaviors towards others. Facility staff found Resident #1 alone and fully naked sitting on an empty bed with Resident #3's hands on Resident #1's genitals, and staff failed to report this to the facility Administrator or Director of Nursing. The following day, Resident #1 lead Resident #2 into a room, removed his/her pants and was seen by facility staff, holding Resident #2's hand on Resident#1's genitals. The facility census was 29. The administrator was notified on 2/22/24 at 10:30 A.M. of an Immediate Jeopardy (IJ) which began on 1/19/24. […]

• Immediate jeopardy, isolatedF684Oct 5, 2022

  Based on observation, interview, and record review, facility staff failed to assess one resident (Resident #140) thoroughly and notify the resident's physician when he/she had a change in condition and [CONDITION(S)]-like activity. The facility failed to assess thoroughly, notify the physician, and transport the resident using Emergency Medical Services (EMS) after the resident had another [CONDITION(S)]-like activity and became unresponsive with agonal (labored and loud with long pauses) respirations. Facility staff further failed to properly assess, notify physician, and attempt to remove the resident's indwelling urinary catheter appropriately that became dislodge and stuck in his/her urethra. The resident was pronounced deceased at 12:06 P.M. […]

• Actual harm, isolatedF600May 1, 2026

  Based on interview and record review the facility failed to ensure one resident (Resident #1) was free from abuse when Resident #1 was pushed onto the floor by Resident #2 which caused two skin tears on Resident #1's left arm after Resident #1 went into Resident #2's room due to confusion. This affected one of four sampled residents. The facility census was 28.Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, showed residents had the right to be free from abuse. This included by was not limited to freedom from corporal punishment, verbal, mental, or physical abuse. […]

• Actual harm, isolatedF600Apr 21, 2026

  Based on observation, interview, and record review the facility failed to protect the resident's right to be free from physical abuse when C.N.A. A slapped Resident #1 on the hand with his/her open hand and forced the residents' hands down into his/her lap twice while in the dining room for a meal. This effected one of three sampled residents. The facility census was 25. Review of the facilities Abuse, Neglect, and Exploitation policy, dated 1/31/24, showed:-Abuse means the willful infliction injury, intimidation, or punishment resulting in physical harm, pain or mental anguish, which can include staff to resident abuse;-New employees will be educated on abuse during initial orientation and existing staff will receive annual education through planned in-services and as needed;-Training… […]

• No harm, potential for more than minimal, widespreadF727Aug 21, 2025

  Based on interviews and record review, the facility failed to ensure they employed a Registered Nurse (RN) for eight consecutive hours per day, seven days per week. The facility census was 31. The facility did not provide the requested nurse staffing policy.Review of the staffing sheets for January 2025 showed:- No RN scheduled for eight consecutive hours 01/01, 01/04, 01/05, 01/11,01/12, 01/18 and 01/19;Review of the staffing sheets for February 2025 showed:- No RN scheduled for eight consecutive hours 02/01, 02/02,02/08,02/09,02/15 and,02/23;Review of the staffing sheets for March 2025 showed:- No RN scheduled for eight consecutive hours 03/08,03/09,03/22,03/23.During an interview on 08/21/2025 at 11:46 A.M., the Administrator and the Director of Nursing (DON) said:- They should have an… […]