KANSAS CITY, MO - A February 2025 inspection at Highland Rehabilitation & Health Care Center uncovered significant deficiencies in resident safety protocols, medication management, and infection control practices that put vulnerable residents at risk.
Physical Restraint Incident Raises Serious Concerns
Federal inspectors documented a concerning incident involving a newly admitted resident with Huntington's disease who was physically lifted and carried by staff members, restricting their ability to move independently. The resident, identified as Resident #386, weighed only 77.4 pounds at admission on January 30, 2025, and had documented ability to walk independently without assistance.
According to investigation records, on February 1, 2025, a certified medication technician (CMT) picked up the resident by the waist from behind during a smoking break dispute with another resident. Multiple staff members confirmed the CMT carried the resident approximately five feet indoors, and later picked up the resident a second time to transport them to their room—a distance described as "the width of one resident's room."
The incident began when Resident #386 attempted to take a lit cigarette from another resident on the facility's smoking patio. Rather than using verbal redirection or other de-escalation techniques, the CMT physically restrained the resident by lifting them off the ground, preventing independent ambulation.
Federal regulations define manual restraint as holding or limiting a resident's voluntary movement through body contact. When staff members carry a resident who is capable of walking independently, they are effectively restraining that person's freedom of movement without proper authorization or medical necessity.
Medical Context: Why Physical Intervention Methods Matter
Physical interventions that restrict movement can have serious consequences for nursing home residents, particularly those with neurological conditions like Huntington's disease. When staff use physical force to redirect residents, several risks emerge beyond the immediate violation of residents' rights.
First, physically lifting and carrying residents who can ambulate independently undermines their functional abilities. Research in geriatric care demonstrates that when staff perform tasks residents can do themselves, it accelerates functional decline—a phenomenon known as "excess disability." For residents with progressive neurological conditions, maintaining mobility and independence is critical to slowing disease progression.
Second, physical interventions can cause psychological trauma, particularly for residents with cognitive impairments who may not understand why they are being restrained. The resident in this case reported feeling "manhandled" and showed visible signs of distress, including bruising and scratches on both arms.
Third, improper physical handling techniques can result in injuries. Residents in nursing facilities often have fragile skin, brittle bones, and multiple medical conditions that make them vulnerable to injury from physical contact. A 77-pound resident with Huntington's disease faces particular risk given the involuntary movements characteristic of the condition.
The facility's own interim Director of Nursing acknowledged that staff should have used alternative intervention strategies, including standing between residents, obtaining assistance from additional staff members, or offering food or medication to address the underlying cause of the resident's agitation. The facility's Administrator admitted the CMT used "poor judgment" and violated the resident's right to move independently.
Missing Resident Case Reveals Supervision Gaps
Inspectors identified critical failures in resident supervision when Resident #96 left the facility on January 24, 2025, and remained missing for four days. The resident, who used a wheelchair and had diagnoses of alcohol abuse and psychoactive substance abuse, signed out at 10:40 AM to visit the downtown library but never returned as expected.
The facility's own policy required staff to initiate contact procedures if a resident did not return within one hour of their anticipated return time. However, staff did not begin looking for the resident until the following day. Evening shift staff on January 24 noticed the resident was missing around 6:30-7:00 PM—approximately eight hours after departure—but no immediate action was taken.
Documentation revealed the resident was found on January 28, 2025, being pushed in their wheelchair near 39th and Main Street by a passerby who brought them back to the facility. During the four days away, the resident had visited a hospital emergency room, became verbally aggressive with nurses, left against medical advice, and spent time on the streets. When the resident returned, their clothes were visibly soiled, and they had no recollection of being gone for four days.
The delayed response occurred despite the facility having a written policy specifying step-by-step procedures for responding to residents who don't return as expected. These procedures included contacting the Administrator, checking sign-out logs, calling the intended destination, notifying the resident's representative and provider, contacting emergency departments, and notifying police.
Nursing home residents who leave facilities and don't return face numerous dangers, including exposure to weather, dehydration, medication interruption, injury, and victimization. For residents with substance abuse disorders, unsupervised time away from the facility can result in intoxication, impaired judgment, and life-threatening situations. The facility's care plan for this resident specifically noted a pattern of leaving the facility, drinking alcohol, and returning intoxicated.
Medication Errors Leave Resident Without Critical Drugs
The inspection revealed that Resident #339 did not receive ordered medications for multiple days following admission on January 31, 2025. The resident missed doses of amlodipine (blood pressure medication), metoprolol (heart medication), lovastatin (cholesterol medication), and levothyroxine (thyroid medication) on February 1-3, 2025, despite these medications being physically present in the facility.
According to investigation findings, the pharmacy delivered nine tablets of each medication on January 31, 2025 at 11:19 PM. However, the medications were placed in a locked nurses' room rather than in the medication cart where staff could access them. Multiple staff members documented the medications as "not in stock" on February 1 and February 2, when in fact the medications were available but misplaced.
Medication errors of this type can have serious health consequences. Amlodipine and metoprolol control hypertension and heart rate—missing multiple doses can lead to dangerous blood pressure elevation and cardiac complications. Levothyroxine replacement is critical for patients with hypothyroidism; interruption can cause fatigue, cognitive dysfunction, and metabolic disturbances. Lovastatin manages cholesterol levels, and while missing a few doses is less immediately dangerous, it still represents a failure to follow physician orders.
The facility's own policies required staff to contact the pharmacy or supervisor when medications were not available and to use the emergency medication kit when appropriate. While some of the needed medications were available in the emergency kit (though in different strengths), no staff member accessed the emergency supply. The medications remained undiscovered in the nurses' cart until February 3, 2025, when the Assistant Director of Nursing found them.
Investigation Failures and Missing Documentation
When Resident #96 went missing, the facility failed to conduct a thorough investigation as required by its own policies. The facility's abuse prevention policy specified that every employee working on the specific unit during the incident should be interviewed and complete statements. However, the investigation file contained no staff interviews and no follow-up five-day final report was submitted to the state survey agency.
The Administrator acknowledged during interviews that "in hindsight, I should have interviewed everyone" and admitted "no one has ever said anything about that before." This statement raises questions about the facility's understanding of federal investigation requirements and its oversight of compliance procedures.
Additional Issues Identified
The inspection also documented failures in preadmission screening requirements, with two residents (Resident #45 and Resident #23) receiving new mental illness diagnoses without having their Level I Preadmission Screening and Resident Reviews (PASRRs) updated as required. Resident #73, who had a diagnosis of post-traumatic stress disorder stemming from childhood abuse and experiencing ongoing nightmares, had no care plan addressing this condition or identifying potential triggers that could cause re-traumatization.
Infection control violations included staff failing to wear required personal protective equipment when caring for two residents who needed enhanced barrier precautions due to feeding tubes and urinary catheters. One resident's catheter drainage bag and tubing were found lying on the floor—a serious infection control breach. Food safety issues were documented, including staff not wearing beard guards in food preparation areas and multiple food items stored without proper dating or covering.
The February 2025 inspection resulted in findings of minimal harm across multiple regulatory areas, indicating systemic issues with the facility's oversight of resident care, staff training, and policy implementation. While facility leadership acknowledged the deficiencies during interviews, the pattern of violations suggests deeper problems with supervision, accountability, and quality assurance systems.
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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