Highland Manor of Fallon: 22 Deficiencies Found - NV
On August 27, 2025, the director of nursing told federal inspectors that skin assessment was part of the admission process. But she confirmed the assessment for Resident #99 completely missed the resident's dry, red, and swollen skin on their hands and arms.
The facility's own policy, implemented just four months earlier on April 11, 2025, explicitly required licensed or registered nurses to conduct full body skin assessments during admission and weekly thereafter. The policy stated nurses must thoroughly examine residents' skin for conditions including redness, and document all observations.
Highland Manor's failure represents a fundamental breakdown in basic nursing care. Skin assessments serve as the first line of defense against pressure ulcers, infections, and other serious complications that can develop rapidly in elderly residents. Missing obvious signs like redness and swelling during admission means problems can progress unchecked.
The inspection report indicates this violation affected few residents but carried potential for actual harm. Federal regulators classify such oversights as serious enough to warrant formal citation, particularly when facilities have written policies they fail to follow.
The director of nursing's admission that staff missed the resident's skin condition suggests either inadequate training or insufficient oversight of admission procedures. Dry, red, and swollen skin are visible symptoms that should be immediately apparent to any licensed nurse conducting a proper assessment.
Highland Manor's policy was relatively new, implemented less than five months before the inspection. This timing raises questions about whether staff received adequate training on the updated procedures or if the facility was properly monitoring compliance with its own standards.
The facility operates as Highland Manor of Fallon Rehabilitation LLC, indicating it provides both long-term care and rehabilitation services. Residents in rehabilitation often have compromised immune systems or healing wounds, making thorough skin assessments even more critical to prevent complications.
Federal inspectors cross-referenced this violation with two other deficiencies, suggesting Highland Manor's problems with skin care may be part of a broader pattern of inadequate resident assessment and monitoring.
The missed skin assessment occurred during what should be one of the most thorough evaluations a resident receives. Admission assessments establish baselines for all aspects of a resident's health and identify existing conditions that require ongoing monitoring or treatment.
When nurses fail to document obvious skin problems during admission, it creates a cascade of problems. Without proper documentation, the resident may not receive appropriate treatments. Care plans may be inadequate. And staff on subsequent shifts may not know to monitor the affected areas.
The violation occurred in late August, during Nevada's hottest months when skin conditions can be exacerbated by heat and dehydration. Elderly residents are particularly vulnerable to skin breakdown during summer months, making thorough assessments even more crucial.
Highland Manor's policy required weekly skin assessments after admission, but the failure to properly conduct the initial evaluation undermines the entire monitoring system. If nurses miss obvious problems during the comprehensive admission assessment, the reliability of subsequent weekly checks becomes questionable.
The facility's admission that its own director of nursing confirmed the assessment failure suggests Highland Manor recognized the seriousness of the oversight. However, the inspection report provides no indication of what steps, if any, the facility took to address the missed assessment or prevent similar failures.
Federal inspectors completed their review on September 4, 2025, just over a week after the director of nursing's admission about the inadequate skin assessment. The timing suggests inspectors moved quickly to document the violation once the facility acknowledged the problem.
The case of Resident #99 illustrates how basic nursing care failures can slip through even when facilities have appropriate policies in place. Having written procedures means nothing if staff don't follow them or supervisors don't ensure compliance.
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 21, 2026 · Our methodology
HIGHLAND MANOR OF FALLON REHABILITATION LLC in FALLON, NV was cited for violations during a health inspection on September 4, 2025.
On August 27, 2025, the director of nursing told federal inspectors that skin assessment was part of the admission process.
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.