Highland Hills Post Acute: Nurse Yelled at Dementia Resident - PA

The nurse had worked at the facility since April 1994. She had completed abuse prevention retraining seven months before the incident.

The woman at the center of the report, identified in inspection documents only as Resident R167, had been diagnosed with dementia, diabetes, and elevated lipid levels. Her care plan included a specific instruction: if conflict arises, place her in a calm and safe environment and allow her to vent. On the afternoon of November 19, 2025, none of that happened.

At around 12:30 p.m. that day, the facility's Assistant Director of Nursing walked into Resident R167's room and found a certified nursing aide and the licensed practical nurse in the middle of transferring the resident from her bed to her wheelchair using a sit-to-stand lift. What the Assistant Director of Nursing heard stopped her.

The licensed practical nurse was yelling at the resident. "Stop it, you aren't a child. Stop acting like it."

The Assistant Director of Nursing also observed that the licensed practical nurse appeared to push Resident R167 down into the chair while the sling from the lift was still wrapped around her waist.

The certified nursing aide who was present in the room that afternoon confirmed in a written witness statement that the licensed practical nurse had yelled at Resident R167. The aide's account matched what the Assistant Director of Nursing had seen and heard walking through the door.

A sit-to-stand lift is a mechanical device used to transfer residents who have limited ability to bear weight on their own. The sling is positioned around the resident's body to support them during the transfer. Pushing a resident into a seated position while the sling remains in place creates a risk of injury and removes the resident's control over her own movement during a moment of physical vulnerability.

Resident R167 has dementia, a condition that progressively erodes memory and cognitive function. She cannot necessarily explain what happened to her, advocate for herself in the moment, or reliably recall the incident afterward. She was dependent on the staff in that room for her physical safety.

The licensed practical nurse had received annual retraining on the psychosocial needs of residents in November 2024 and completed annual abuse prevention education in April 2025, seven months before she yelled at a woman with dementia while lowering her into a chair.

The inspection was triggered by a complaint and conducted on December 19, 2025. Inspectors reviewed facility policies, clinical records, the facility's own investigation documents, and conducted staff interviews. The citation issued was F0600, covering the protection of residents from abuse, neglect, and exploitation. The level of harm was assessed as minimal harm or potential for actual harm.

That classification, minimal harm or potential for actual harm, is the lower end of the federal harm scale. It does not mean nothing happened. It means inspectors determined the resident was not documented as having suffered a physical injury. A woman with dementia was screamed at by someone responsible for her care, pushed into a chair while still strapped into a mechanical lift, and the federal designation is that she experienced minimal harm.

During an interview on December 16, the Assistant Director of Nursing described the incident to inspectors directly. She told them that the licensed practical nurse pushed Resident R167 down into the chair while the resident was still hooked to the sit-to-stand machine and the sling was still around her. She confirmed the nurse yelled in the resident's face.

The facility's own abuse prevention policy, dated November 1, 2025, less than three weeks before the incident, states that residents have the right to be free from abuse, neglect, and exploitation.

Inspectors informed the Director of Nursing and the Nursing Home Administrator of the findings on December 17, 2025.

The inspection report does not say whether the licensed practical nurse remains employed at the facility. It does not describe any disciplinary action taken. It does not say whether Resident R167 or her family was notified, or what, if anything, was communicated to her about what had been witnessed in her room.

What the record shows is this: a woman with dementia, dependent on a mechanical lift to move from her bed to her wheelchair, was yelled at and pushed by a nurse who had worked at the same building for more than thirty years. Another staff member watched it happen. A supervisor walked in mid-incident and saw it herself. The facility opened an investigation the same day, gathered a witness statement, and documented the clinical details in a nurse's note.

The care plan for Resident R167 said to place her in a calm and safe environment if conflict arose. It said to allow her to vent. She was in her own room, being helped into her wheelchair. There was no conflict until the nurse created one.

Resident R167's admission record shows she had been admitted and readmitted to the facility. She lives there. The staff in that room, the one yelling and the one watching, are among the people she relies on every day for her most basic physical needs, getting out of bed, getting into a chair, moving through her day.

The inspection report does not record what Resident R167 said or did in the moments before the nurse began yelling. It does not explain what prompted the outburst. It records only what was witnessed: a nurse telling a woman with dementia that she was acting like a child, and then pushing her into a seat while she was still caught in the sling of the machine that was supposed to be keeping her safe.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Highland Hills Post Acute from 2025-12-19 including all violations, facility responses, and corrective action plans.

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