Highland Manor Fallon: Infection Control Failures - NV
The facility's Director of Nursing confirmed on August 27 that the skin assessment for Resident #99 did not include the visible skin problems, despite acknowledging that skin assessments were mandatory parts of admission evaluations.
Highland Manor's own policy, implemented just four months earlier in April, required licensed or registered nurses to conduct full-body skin assessments on every admission and re-admission. The policy specifically mandated weekly follow-up examinations thereafter.
The written policy left no room for interpretation. Staff were directed to thoroughly examine residents' skin for all conditions, explicitly including redness. All observations were supposed to be documented in the medical record.
Federal inspectors found the facility violated basic care standards by failing to follow its own protocols. The missed documentation occurred despite the resident's skin conditions being readily visible to staff during the admission process.
The violation represents a breakdown in fundamental nursing care. Skin assessments serve as critical baseline documentation for tracking changes in residents' conditions over time. Without proper initial documentation, staff cannot monitor whether skin problems improve, worsen, or develop into more serious complications.
Highland Manor's policy had been in effect for less than five months when the violation occurred. The facility implemented the skin assessment requirements on April 11, 2025, suggesting recent awareness of the need for comprehensive skin evaluations.
The Director of Nursing's acknowledgment that skin assessments were part of admission procedures made the oversight more significant. The nursing leadership understood the requirement but failed to ensure staff completed the documentation properly.
Resident #99's dry, red, and swollen skin on both hands and arms should have triggered immediate documentation and likely additional medical evaluation. These symptoms can indicate various conditions requiring different treatments, from allergic reactions to circulatory problems.
The inspection report classified the violation as causing minimal harm or potential for actual harm to few residents. However, the failure to document existing skin conditions could have prevented proper treatment planning and monitoring.
Federal regulations require nursing homes to assess each resident's physical condition upon admission to establish baseline health status. Comprehensive skin assessments help identify existing problems and prevent development of pressure ulcers and other complications.
The missed documentation also violated Highland Manor's commitment to conduct head-to-toe examinations. The policy's language was unambiguous about examining the entire body, not just selected areas.
Weekly skin assessments following admission become meaningless without accurate baseline documentation. Staff cannot track improvement or deterioration in skin conditions they never officially recorded in the first place.
The violation occurred during a complaint investigation, suggesting someone reported concerns about care quality at Highland Manor. Federal inspectors found the skin assessment failure while examining broader care issues at the facility.
Highland Manor operates as a rehabilitation facility, serving residents who may have compromised skin integrity from medical conditions or limited mobility. Proper skin assessment becomes even more critical in rehabilitation settings where residents may be recovering from surgeries or managing chronic conditions.
The facility's failure to follow its four-month-old policy raises questions about staff training and supervision. New policies require consistent implementation and oversight to become effective practice.
Without proper documentation of Resident #99's skin conditions, the facility cannot demonstrate it provided appropriate care or monitoring for the red, swollen areas. The missing assessment creates gaps in the resident's medical record that could affect future treatment decisions.
The inspection report cross-referenced the skin assessment violation with two other deficiencies, suggesting Highland Manor faced multiple care quality issues during the federal review.
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 policy specifically mandated weekly follow-up examinations thereafter.
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.