FALLON, NV — Federal health inspectors identified 22 deficiencies at Highland Manor of Fallon Rehabilitation LLC during a complaint investigation completed on September 4, 2025, including a citation for failing to maintain an adequate infection prevention and control program.
Infection Prevention Program Found Deficient
The Centers for Medicare & Medicaid Services (CMS) cited Highland Manor under regulatory tag F0880, which requires skilled nursing facilities to provide and implement a comprehensive infection prevention and control program. Inspectors determined that the Fallon facility fell short of this federal standard.
The deficiency was classified at Scope/Severity Level D, meaning the problem was isolated in scope and did not result in documented actual harm to residents. However, regulators noted there was potential for more than minimal harm — a designation that signals real risk even in the absence of an immediate adverse outcome.
Infection control programs in nursing homes are designed to prevent the spread of bacterial, viral, and fungal pathogens among a population that is particularly vulnerable. Residents of skilled nursing facilities often have compromised immune systems, chronic wounds, indwelling catheters, and other medical devices that create direct pathways for infection. Without a functioning prevention program, common pathogens such as MRSA, C. difficile, influenza, and urinary tract infections can spread rapidly through a facility.
A properly implemented infection control program includes staff hand hygiene protocols, proper use of personal protective equipment, environmental cleaning schedules, isolation procedures for contagious residents, antibiotic stewardship, and ongoing surveillance to detect outbreaks early. When any component of this system breaks down, the consequences for elderly and medically fragile residents can be severe.
22 Total Deficiencies Signal Broader Compliance Issues
The infection control citation was not an isolated finding. Highland Manor was cited for 22 total deficiencies during the September 2025 inspection, a number that raises questions about the facility's overall compliance posture.
For context, the average number of deficiencies per inspection at skilled nursing facilities nationwide typically ranges between 7 and 9. A count of 22 places Highland Manor well above the national average and suggests systemic issues that extend beyond any single regulatory area.
The inspection was triggered by a complaint investigation, meaning that concerns about the facility were raised — potentially by residents, family members, or staff — prior to the inspection taking place. Complaint-driven inspections differ from routine annual surveys in that they are typically focused on specific allegations, though inspectors may expand the scope of their review when additional problems are observed.
What Federal Regulations Require
Under federal law, all Medicare- and Medicaid-certified nursing homes must maintain an infection prevention and control program that is overseen by a designated Infection Preventionist. This individual, who must have specialized training in infection control, is responsible for developing facility-wide policies, conducting surveillance, and ensuring staff compliance with protocols.
The regulation under F0880 specifically requires facilities to establish a system for preventing, identifying, reporting, investigating, and controlling infections. This includes maintaining written policies, conducting regular staff education, tracking infection rates, and implementing corrective actions when lapses are identified.
Facilities that fail to meet these standards place residents at elevated risk for healthcare-associated infections (HAIs), which are among the leading causes of illness and death in long-term care settings. According to published research, approximately 1 to 3 million serious infections occur in long-term care facilities across the United States each year.
Correction Timeline and Current Status
Highland Manor reported that the deficiency was corrected as of October 17, 2025, approximately six weeks after the inspection. CMS records indicate that no revisit was required, meaning regulators accepted the facility's plan of correction without conducting a follow-up on-site inspection.
While the "no revisit needed" designation indicates that CMS considered the facility's corrective action plan credible, it does not involve independent verification that changes have been fully implemented and sustained.
What Families Should Know
Families with loved ones at Highland Manor of Fallon Rehabilitation or those considering placement should review the facility's full inspection history, which is publicly available through the CMS Care Compare website. The 22 deficiencies cited in September 2025 represent a significant volume of findings that warrant careful review.
Residents and families have the right to ask facility administrators about specific corrective actions taken in response to inspection findings, including what changes were made to the infection control program, what additional staff training was conducted, and how the facility plans to prevent recurrence.
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.