Highland Manor Fallon: 22 Deficiencies, Bed Safety - NV
The admission oversight came to light during a complaint investigation completed September 4. Federal inspectors documented that nursing staff conducted only a partial skin assessment on Resident 99, missing obvious skin conditions on the person's hands and arms.
Highland Manor's own policy, implemented April 11, explicitly requires licensed or registered nurses to conduct full body skin assessments upon admission and weekly thereafter. The policy states that residents' skin "would be thoroughly examined for skin conditions, including redness" and that "observations would be documented."
The director of nursing acknowledged on August 27 at 2:58 PM that skin assessment was indeed part of the standard admission process. She confirmed that the assessment for Resident 99 "did not include the resident's dry, red, and swollen skin to the resident's hands and arms."
The violation represents a fundamental breakdown in basic nursing care protocols. Skin assessments serve as critical early detection tools for pressure ulcers, infections, and other conditions that can rapidly deteriorate in elderly residents. Missing obvious skin abnormalities during admission means potential problems go unaddressed from the moment a resident enters the facility.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the deficiency cross-references two additional violations, suggesting broader systemic issues with resident assessment and care planning at the facility.
The missed assessment occurred despite clear documentation requirements. Highland Manor's policy mandates that all observations from skin examinations be properly recorded, creating a paper trail for ongoing care decisions. The failure to assess and document the resident's skin condition leaves gaps in the medical record that could compromise future treatment decisions.
Incomplete admission assessments can have cascading effects throughout a resident's stay. Without baseline documentation of existing skin conditions, staff cannot distinguish between pre-existing issues and new problems that develop during care. This makes it difficult to track whether conditions are improving, worsening, or remaining stable.
The timing of the policy implementation raises additional questions about staff training and compliance monitoring. Highland Manor established its skin assessment policy just four months before the violation occurred, suggesting either inadequate staff education on new procedures or insufficient oversight to ensure policy adherence.
Federal regulations require nursing homes to conduct comprehensive assessments within 14 days of admission to identify each resident's medical, nursing, and psychosocial needs. These assessments form the foundation for individualized care plans that guide daily treatment decisions throughout a resident's stay.
The violation at Highland Manor demonstrates how seemingly minor oversights can indicate broader care quality issues. When basic assessment protocols break down, it suggests potential problems with staff supervision, training, or facility systems designed to ensure consistent care delivery.
Skin conditions left unassessed and undocumented can progress rapidly in elderly residents, particularly those with diabetes, circulation problems, or limited mobility. Early identification and treatment of skin abnormalities are essential for preventing more serious complications that could require hospitalization or cause significant discomfort.
The complaint investigation that uncovered the assessment failure suggests family members or residents may have raised concerns about care quality at Highland Manor. Federal inspectors conduct complaint investigations when they receive allegations of potential violations from residents, families, or facility staff.
Highland Manor of Fallon serves residents requiring rehabilitation and long-term care services in rural Nevada. The facility's failure to complete basic admission assessments raises questions about whether other fundamental care protocols are being consistently followed for the vulnerable elderly population it serves.
The resident whose skin condition went unassessed during admission continues to live with the consequences of that initial oversight, as staff failed to establish proper baseline documentation for ongoing care decisions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highland Manor of Fallon Rehabilitation LLC from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
HIGHLAND MANOR OF FALLON REHABILITATION LLC in FALLON, NV was cited for violations during a health inspection on September 4, 2025.
The admission oversight came to light during a complaint investigation completed September 4.
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.