Highland Manor Fallon: Medication Error Pattern - NV
The facility's director of nursing admitted on August 27 that staff failed to document Resident 99's dry, red, and swollen skin during the required skin assessment. The admission occurred while federal inspectors were investigating a complaint at the 550 North Sherman Street facility.
Highland Manor's own policy, implemented just four months earlier in April, explicitly required licensed nurses to conduct "full body, or head to toe" skin assessments for every admission and readmission. The policy stated that residents' skin "would be thoroughly examined for skin conditions, including redness" and that "observations would be documented."
The director of nursing confirmed that skin assessments were standard parts of admission procedures. Yet when inspectors pressed about Resident 99's case, she acknowledged the assessment had missed the visible skin problems on the patient's hands and arms.
Federal regulations require nursing homes to assess each resident's physical condition upon admission to establish baseline health status and identify immediate care needs. Skin assessments are particularly critical for elderly residents, who face higher risks of pressure sores, infections, and other complications from untreated skin conditions.
The inspection revealed a gap between Highland Manor's written policies and actual practice. While the facility had updated its skin assessment policy in April 2025, staff apparently weren't following the head-to-toe examination requirements consistently.
Resident 99's missed skin problems could have signaled underlying health issues requiring immediate attention. Dry, red, and swollen skin on hands and arms might indicate allergic reactions, circulation problems, infections, or other medical conditions that worsen without proper monitoring and treatment.
The facility's failure occurred during a complaint investigation, suggesting ongoing care quality concerns at Highland Manor. Federal inspectors rarely arrive for unscheduled visits unless they've received reports of potential violations or resident safety issues.
Highland Manor of Fallon Rehabilitation operates under state licensing and federal Medicare certification, which require facilities to maintain comprehensive assessment procedures. The missed skin assessment violated federal tag F684, which governs resident assessment requirements.
The inspection also referenced related violations under tags F655 and F658, indicating the skin assessment failure was part of broader care planning or assessment problems at the facility. These cross-references suggest inspectors found multiple interconnected issues affecting resident care quality.
Highland Manor's policy revision in April 2025 showed the facility recognized the importance of thorough skin assessments. The policy specifically mentioned examining for redness, exactly the type of condition that staff missed on Resident 99's hands and arms.
The director of nursing's admission that the assessment was incomplete came during direct questioning by federal inspectors on August 27. Her acknowledgment provided clear documentation of the facility's failure to follow its own care standards.
Nursing homes face increasing scrutiny over assessment procedures, particularly for skin conditions that can rapidly deteriorate in elderly residents. Proper documentation helps ensure continuity of care and alerts staff to changes that might require medical intervention.
The September 4 inspection classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. However, even minimal harm violations can indicate systemic problems if facilities aren't consistently following basic care protocols.
Highland Manor's failure to document obvious skin problems during admission raises questions about what other conditions might go unnoticed or unreported. Resident 99's red, swollen hands and arms were visible enough that the director of nursing later admitted they should have been included in the assessment.
The facility must now develop a plan of correction addressing how it will ensure staff complete thorough skin assessments as required by both federal regulations and its own policies.
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 occurred while federal inspectors were investigating a complaint at the 550 North Sherman Street facility.
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.