Highland Rehab: Staff Physically Lifted Resident - MO

The incident occurred on February 1, 2025, involving a resident admitted just two days earlier with Huntington's disease, a progressive neurodegenerative disorder. The resident weighed 77.4 pounds and could walk independently without assistance.

Resident 386 had gone to the smoking patio after receiving a cigarette from a nurse. When the resident finished smoking, they tried to take a lit cigarette from another resident. Certified Medication Technician 5 opened the patio door, grabbed the resident by the waist from behind, picked them up, and carried them back inside about five feet.

"CMT 5 stated when the resident would not stop trying to take Resident 64's cigarette, the only other option was to pick the resident up and bring the resident inside," according to the inspection report.

The technician then blocked the patio door because the resident kept trying to go back outside. When the resident turned around to go back toward the door, CMT 5 picked them up again from behind by the waist, carried them to their room, and sat them on the bed.

Certified Nursing Assistant 4 witnessed the incident and told inspectors the resident "snatched, grabbed, punched, and swung their hands at staff" while being carried. CNA 4 acknowledged that "staff were trained not to put their hands on residents."

The facility's own investigation determined CMT 5 violated the resident's rights. The Administrator stated during interviews that CMT 5's actions violated "the resident's right to move independently and the right not to be physically redirected to a different space."

Resident 386 later told staff that workers had "grabbed the resident's arms and threw the resident on the bed." When interviewed by inspectors, the resident showed their arms but no bruises were visible. Licensed Practical Nurse 1 reported seeing red marks and old bruising on the resident's wrists after the incident.

Another medication technician at the facility explained the significance of the violation. "If they [residents] are able to walk and you pick them up, now they can't walk. That's a restraint and we can't put them in a restraint, period," CMT 6 told inspectors.

The facility's restraint policy requires physician orders and assessments before any device or action that restricts a resident's physical ability to move. No such order existed for Resident 386.

The Administrator acknowledged CMT 5 used "poor judgement" but initially argued the action didn't constitute a restraint because "the resident was let go and their arms and legs remained free." However, when pressed by inspectors, the Administrator admitted the resident "could not ambulate when they were picked up by staff."

The Interim Director of Nursing suggested alternative approaches CMT 5 could have used, including standing between the residents, getting another staff member to help redirect, or offering food or medicine to address the root cause of the resident's distress.

CMT 5 was suspended pending investigation and denied throwing the resident on the bed or grabbing them by the wrists during phone interviews with inspectors.

Highland also failed to adequately investigate when another resident disappeared for four days in January. Resident 96, who used a wheelchair and had a history of alcohol abuse, signed out to visit the library on January 24, 2025, at 10:40 AM. The 77-year-old resident dated the sign-out sheet incorrectly and left the planned return time blank.

Staff didn't notice the resident was missing until suppertime the next day. The facility's policy required action within one hour of a missed return time, but staff waited nearly 24 hours before starting search procedures.

The resident was eventually found four days later, wandering at 39th and Main Street, and brought back to the facility by a Good Samaritan. Medical notes revealed the resident had been intoxicated, sent to an emergency room, and then discharged to the street during the missing period.

The facility's investigation consisted only of phone calls to hospitals and jails. No staff interviews were conducted, despite facility policy requiring interviews with "every employee who was working on the specific hall/wing that the affected resident resides on."

"In hindsight, I should have interviewed everyone," the Administrator told inspectors. "We are learning, and no one has ever said anything about that before."

Highland also failed to ensure proper care planning for residents with mental health needs. Resident 73, diagnosed with post-traumatic stress disorder from childhood abuse, had no care plan addressing PTSD triggers or behavioral interventions, despite psychiatric recommendations for behavioral modification strategies.

Staff working with the resident were unaware of the PTSD diagnosis. The MDS Registered Nurse acknowledged the oversight, telling inspectors: "There were a lot of things that might not be right or not have care plans that should be care planned."

The facility violated medication safety requirements when a newly admitted resident missed critical medications for three consecutive days. Resident 339's blood pressure and heart medications were delivered to the facility but placed in the wrong location, preventing staff from administering them.

Certified medication technicians documented "not in stock" for the medications on February 1 and 2, despite the drugs being available in the facility's nurses' room. The resident also missed thyroid medication doses with no documentation explaining the omissions.

Food safety violations included staff entering food preparation areas without required hair coverings, open food containers, and undated prepared foods. A pizza box and month-old sandwich were found in resident refrigerators without proper labeling.

The facility also failed to implement enhanced barrier precautions for residents with feeding tubes and catheters. Staff provided care without required gowns and gloves, and one resident's catheter drainage bag was observed lying on the floor.

Highland Rehabilitation serves 129 residents on East 68th Street in Kansas City. The facility was cited for violations affecting resident rights, safety, medication management, and infection control during the February 2025 inspection.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Highland Rehabilitation & Health Care Center from 2025-02-08 including all violations, facility responses, and corrective action plans.

Additional Resources

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