Highland Manor Fallon: Food Safety Deficiency - NV
The Director of Nursing at Highland Manor of Fallon Rehabilitation LLC confirmed on August 27 that the skin assessment for Resident #99 did not include the resident's dry, red, and swollen skin on their hands and arms. Federal inspectors documented the admission as a violation of Medicare standards for comprehensive resident assessments.
The DON acknowledged that skin assessments were supposed to be part of every admission evaluation. But when inspectors reviewed the case, they found the facility had failed to follow its own policies for documenting skin conditions that were clearly present when the resident arrived.
Highland Manor's written policy, implemented just four months earlier in April, required a "full body, or head to toe" skin assessment by licensed or registered nurses upon admission and weekly thereafter. The policy specifically stated that resident skin would be "thoroughly examined for skin conditions, including redness" and that all observations would be documented.
The policy left no room for interpretation about what constituted a complete assessment.
Yet staff somehow missed the resident's hands and arms entirely, despite the policy's requirement for head-to-toe examination. The skin problems weren't subtle — inspectors described them as dry, red, and swollen, conditions that would have been immediately visible to anyone conducting a proper assessment.
The failure occurred during one of the most critical periods in a nursing home resident's care. Admission assessments establish baseline health conditions and identify existing problems that need immediate attention or monitoring. Missing skin problems at admission can lead to delayed treatment and worsening conditions.
Federal regulations require nursing homes to conduct comprehensive assessments within 14 days of admission, with preliminary assessments completed much sooner. These evaluations must identify residents' medical, nursing, and psychosocial needs to ensure appropriate care planning.
Skin assessments hold particular importance in nursing home care because residents often have limited mobility and may be at high risk for pressure sores, infections, and other skin-related complications. Early identification allows staff to implement preventive measures and appropriate treatment protocols.
The violation occurred despite the facility having updated its skin assessment policy in April 2025, just months before the incident. The policy appeared comprehensive on paper, requiring thorough documentation of all skin conditions and regular follow-up assessments.
But policies mean nothing without proper implementation and staff compliance.
The inspection report noted that this deficiency was cross-referenced with two other violations — F655 and F658 — suggesting the incomplete skin assessment was part of a broader pattern of assessment failures at Highland Manor.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the classification doesn't diminish the significance of missing obvious medical conditions during admission.
For Resident #99, the missed documentation meant that red, swollen skin on their hands and arms went unrecorded in their medical record. Without proper documentation, subsequent caregivers might not know about the conditions or monitor them appropriately.
The resident's actual medical outcome remains unclear from the inspection report, but the failure represents exactly the kind of oversight that federal regulations are designed to prevent.
Highland Manor's admission assessment process clearly broke down in this case, with staff either not looking carefully enough or not documenting what they saw. Either scenario represents a failure in basic nursing care standards.
The DON's acknowledgment of the incomplete assessment suggests the facility recognized the problem once inspectors identified it. But recognition after the fact doesn't help residents who depend on accurate medical assessments from the moment they enter the facility.
For families placing loved ones in Highland Manor, the violation raises questions about whether other admission assessments have been similarly incomplete and what other medical conditions might have been overlooked during the critical first days of nursing home care.
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.
Federal inspectors documented the admission as a violation of Medicare standards for comprehensive resident assessments.
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.