Highland Manor of Elko: Call Light Out of Reach - NV
The call light was there. It just wasn't reachable. Someone had draped it over the running oxygen concentrator beside her bed.
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See the Derila PillowFederal inspectors documented the situation on July 15, 2024, at 1:25 in the afternoon. Resident #53, whose diagnoses included unspecified dementia with agitation, muscle weakness, and anxiety disorder, was in bed when inspectors observed the call light hanging over the concentrator, out of her reach. Her care plan, revised just that same day, noted she was at risk for falls and required one-person assistance for any transfer out of bed. The plan specifically directed staff to encourage her to call for help before getting up.
She couldn't.
Five minutes later, at 1:30 PM, a certified nursing assistant walked into the room and couldn't immediately locate the call light at all. When the CNA finally found it draped over the oxygen concentrator, she moved it and attached it to the resident's blanket. The CNA confirmed to inspectors what was already apparent: while the call light was on the concentrator, Resident #53 could not reach it. Her only option, the CNA said, would have been to yell.
Two days later, a licensed practical nurse told inspectors the same thing. The resident knew how to use the call light. She used it when she needed help. But if it was on the oxygen concentrator, she couldn't get to it.
The facility's own policy on responding to resident needs, last revised in October 2010, states that when a resident is in bed or confined to a chair, the call light must be within easy reach. That policy existed before this resident was ever admitted. It existed before her fall risk was documented, before her dementia progressed, before her care plan was written and revised.
None of that made a difference on the afternoon of July 15.
What makes the finding particularly stark is the specificity of this resident's situation. She wasn't a resident with minor limitations. Her care plan flagged her as needing an extensive one-person assist for something as basic as standing and pivoting. Incontinence was listed among her fall risk factors, which means the moments when she might feel urgency to get up, to move, to transfer without waiting, were predictable. The care plan's answer to that risk was to make sure she called for help first.
The call light is the whole system. For a resident who cannot safely get out of bed alone, cannot reliably summon the physical reserves to manage a transfer, and lives with dementia that complicates her ability to problem-solve in a crisis, the call light isn't a convenience. It's the mechanism that stands between her and a fall.
Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, the lower end of the scale. The citation covered one of 18 sampled residents.
The inspection was completed July 18, 2024. The facility is located at 2850 Ruby Vista Drive in Elko.
What the report doesn't answer is how long the call light had been on the concentrator before 1:25 PM, or how many times before this inspection it had ended up there. The CNA who walked in at 1:30 said she couldn't find it at first. That suggests it wasn't where anyone expected it to be. It suggests this wasn't the first time something had gotten moved and left somewhere it didn't belong.
Resident #53 knew how to use the call light. On July 15, that didn't matter.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Manor of Elko Rehabilitation LLC from 2024-07-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 14, 2026 · Our methodology
HIGHLAND MANOR OF ELKO REHABILITATION LLC in ELKO, NV was cited for violations during a health inspection on July 18, 2024.
Someone had draped it over the running oxygen concentrator beside her bed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.