KANSAS CITY, MO - Federal inspectors documented serious safety violations at Highland Rehabilitation & Health Care Center following a February 2025 investigation, including improper physical restraint of a cognitively impaired resident and failure to respond when another resident went missing for four days after leaving for a library visit.
Physical Restraint Incident Involving Huntington's Disease Resident
Highland Rehabilitation staff physically lifted and carried a 77-pound resident with Huntington's disease against their will on February 1, 2025, violating federal regulations prohibiting unauthorized restraints. The incident occurred when the newly admitted resident attempted to take a cigarette from another resident on the facility's smoking patio.
According to facility records, Resident #386 had been admitted just two days prior with diagnoses including Huntington's disease, a progressive neurodegenerative disorder causing uncontrolled movements and cognitive decline. Despite documentation showing the resident could walk independently and did not require mobility assistance, a certified medication technician (CMT) physically intervened when the resident tried to take another resident's cigarette.
The CMT grabbed the resident around the waist from behind, lifted them off their feet, and carried them approximately five feet inside the building. When the resident attempted to return to the patio area, the CMT again picked them up and carried them to their room, placing them on the bed. Multiple staff witnesses confirmed these actions during the investigation.
The physical intervention violated fundamental resident rights and constituted an improper restraint. When residents can ambulate independently, forcibly picking them up and carrying them restricts their voluntary movement and freedom of motion. This meets the regulatory definition of physical restraint, which requires physician orders, proper documentation, and should only be used in specific emergency situations to prevent imminent harm.
The facility's own restraint policy defines restraints as anything that hinders a resident's ability to move freely. Yet when interviewed, facility leadership attempted to minimize the incident. The Interim Director of Nursing stated that while the CMT's actions were "a poor choice," they did not constitute a restraint because "the resident was let go and their arms and legs remained free." This interpretation contradicts established standards - a resident who can walk independently cannot do so while being physically carried by staff.
Four-Day Disappearance Following Library Visit
In a separate incident highlighting supervision failures, Resident #96 disappeared for four days after signing out to visit the library on January 24, 2025, yet staff failed to initiate proper search protocols until the following morning. The resident, who had documented alcohol abuse issues and required a manual wheelchair for mobility, signed out at 10:40 AM but never indicated a return time.
The facility's policy required staff to begin search procedures within one hour if a resident failed to return at their anticipated time, or after four hours if no return time was documented. Despite the resident's absence being noticed at dinner time - approximately eight hours after departure - evening staff took no meaningful action beyond checking the sign-out book.
When evening staff discovered the resident missing around 6:30 PM, they notified the staffing coordinator who called an assistant director of nursing. However, neither manager initiated the facility's missing person protocol. No attempts were made that evening to contact the library (which closed at 6:00 PM), search the community, notify police, or contact local hospitals.
The gravity of this failure becomes clear considering the resident's vulnerabilities. Medical records showed a history of alcohol abuse, previous incidents of returning to the facility intoxicated, and physical limitations requiring wheelchair use. The resident's care plan specifically directed staff to monitor for signs of substance use and included detailed assessment protocols for intoxication symptoms.
Police were not notified until the following morning - nearly 24 hours after the resident left the facility. When officers investigated, they discovered the resident had visited the emergency room Friday evening, became verbally aggressive with nurses, and left against medical advice around 11:30 PM. The resident then spent four days on the streets in winter conditions.
On January 28, the resident was found "wandering around 39th and Main Street" by a good Samaritan who pushed the resident's wheelchair back to the facility. Documentation revealed the resident arrived with visibly soiled clothing, no recollection of the four-day absence, and required immediate assistance with toileting and personal care.
Medical Analysis: Understanding the Severity
The restraint incident represents more than procedural violations - it posed direct risks to a vulnerable resident with a progressive neurological condition. Huntington's disease causes involuntary movements, balance problems, and increased fall risk. Forcibly lifting and carrying someone with this condition could trigger involuntary muscle contractions, cause injury from sudden movements, or result in falls if the person struggles.
Physical restraints in healthcare settings are associated with serious complications including pressure injuries, contractures, incontinence, psychological trauma, and even death from asphyxiation or cardiac stress. Federal regulations strictly limit restraint use precisely because of these documented risks. Restraints require comprehensive assessment, physician involvement, and should only be considered when less restrictive interventions have failed and the resident poses imminent danger to themselves or others.
The missing resident incident exemplifies catastrophic supervision failure. A resident with documented cognitive issues, substance abuse history, and mobility limitations requiring wheelchair use was essentially abandoned for 96 hours in winter conditions. The delayed response prevented timely medical intervention when the resident experienced a crisis at the hospital emergency department.
Extended exposure without proper shelter, nutrition, hydration, or medication management could have resulted in hypothermia, dehydration, medication withdrawal, injuries from falls, or death. The resident's inability to recall the four-day period suggests possible medical crisis, intoxication, or trauma during the absence.
Additional Issues Identified
The investigation revealed systemic problems with the facility's response to safety incidents. Despite policy requirements to complete thorough investigations within five business days, including staff interviews and comprehensive documentation, the facility failed to properly investigate the missing resident incident. No staff interviews were conducted, and no final five-day investigation report was submitted to state authorities as required.
The facility also failed to follow its own protocols for resident sign-out procedures. Staff did not ensure the sign-out form was completed properly (the resident wrote the wrong date), did not verify the resident's planned return time, and did not confirm the resident had appropriate clothing and resources for the outing.
Training deficiencies were evident in staff responses to both incidents. Multiple employees stated they had never received instruction on when physical intervention might be appropriate or what constituted improper restraint. Staff were unclear about missing person protocols and when to escalate concerns to management or authorities.
The facility operated without an on-site Director of Nursing during these incidents, relying on remote coverage from corporate staff. This leadership gap may have contributed to delayed responses and unclear accountability when serious incidents occurred.
Industry Standards and Protocol Failures
Proper de-escalation techniques are fundamental to dementia and behavioral health care. When the resident attempted to take another's cigarette, staff should have used verbal redirection, offered alternatives, created physical space between residents without touching either person, or engaged the agitated resident in preferred activities. The facility's own leadership identified multiple appropriate interventions including having staff position themselves between residents, offering food or medication to address underlying needs, or simply allowing the situation to resolve naturally.
Missing person protocols in long-term care facilities are designed to trigger immediate response because residents often have cognitive impairments, medical conditions, or physical limitations that make them vulnerable. Industry standards require immediate notification of management, systematic facility searches, and rapid escalation to law enforcement when initial efforts fail. The four-hour window in Highland's policy already exceeds recommended response times, yet staff failed to meet even this extended timeline.
Documentation standards require clear, complete records of resident whereabouts and safety incidents. The facility's acceptance of an improperly completed sign-out form and failure to maintain investigation records demonstrates inadequate quality assurance systems. When the Administrator acknowledged "we are learning" and "in hindsight, I should have interviewed everyone," it revealed a concerning lack of preparedness for managing resident safety incidents.
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.
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