Federal inspectors discovered the practice was routine. During a September complaint investigation, they found five residents positioned in beds with their pants around their ankles or knees, their underwear or adult briefs exposed.
The nursing assistants had a reason for the undignified positioning. One staff member told inspectors that workers "positioned residents in bed with their pants around their ankles so they could have easily checked and changed them."
When inspectors arrived on September 18, they found Resident #2 in bed with his sweatpants around his ankles at 2:48 p.m. The man had Alzheimer's disease. A certified nursing assistant confirmed what inspectors observed and immediately began removing the pants, saying "staff should not have positioned the pants around the resident's ankles."
The assistant then took inspectors on a tour that revealed the scope of the problem. In rapid succession, they found four more residents in similar states of undress.
Resident #3 lay in bed wearing only a brief with sweatpants around his ankles. The nursing assistant removed them.
Resident #4, a woman, was positioned the same way with sweatpants around her ankles over her brief. Again, the assistant removed the clothing.
Resident #5 had sweatpants around his ankles. The assistant removed those too.
Resident #6, another woman, had jeans positioned around her knees while wearing a brief underneath.
The wife of the Alzheimer's patient told inspectors during a follow-up interview that she had observed her husband's pants positioned around his ankles "at various times" during her visits. She "had not liked that at all" and specifically directed staff to remove the pants when she found him that way.
A second nursing assistant confirmed the practice when questioned. The staff member told inspectors that positioning residents' pants around their ankles made it easier for workers to check and change adult diapers during their rounds.
But another nursing assistant interviewed days later acknowledged the practice was wrong. Staff E told inspectors on September 23 that "it had not been acceptable to have positioned residents in bed with their pants around their ankles and/or knees." This assistant said she had also "observed pants around resident's ankles and/or knees at various times."
The facility houses 68 residents. Inspectors reviewed five residents during their complaint investigation and found all five had been subjected to the undignified positioning.
The violation centers on residents' right to dignity and self-determination. Federal regulations require nursing homes to honor residents' right to "a dignified existence" and to exercise their basic rights while receiving care.
For the Alzheimer's patient's wife, the practice represented a fundamental departure from how her husband had lived. The man had never slept with his pants around his ankles when he lived at home with her, she told inspectors.
The nursing assistants' rationale revealed a facility culture that prioritized staff convenience over resident dignity. Rather than removing pants entirely for diaper checks or helping residents dress and undress appropriately, staff had developed a shortcut that left vulnerable residents exposed.
The positioning affected both men and women at the facility. The inspectors found residents wearing various types of lower garments - sweatpants, jeans, and adult briefs - all positioned inappropriately while the residents lay in their beds.
One nursing assistant's immediate response to remove the clothing when inspectors arrived suggested staff understood the positioning was inappropriate, even as the practice had become routine.
The complaint investigation occurred in late September, with inspectors conducting observations and interviews over several days. The facility's failure affected residents with cognitive impairments who could not advocate for themselves, including the man with Alzheimer's whose wife had to repeatedly intervene.
The undignified positioning represented more than a clothing issue. For residents already vulnerable due to cognitive decline and physical dependence, the practice stripped away basic privacy and dignity during intimate care needs.
The wife's insistence that staff remove her husband's pants entirely rather than leave them around his ankles highlighted how family members sometimes must step in to protect residents' dignity when facilities fail to maintain appropriate care standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Highlands from 2025-09-23 including all violations, facility responses, and corrective action plans.