Highland Manor Fallon: Pressure Ulcer Care Failures - NV
The oversight involved Resident #99, whose dry, red, and swollen skin on hands and arms went unrecorded during the admission process on August 27. Federal inspectors discovered the gap during a complaint investigation completed September 4.
When questioned by inspectors at 2:58 PM on August 27, the director of nursing confirmed that skin assessment was indeed part of the admission process. She then acknowledged the assessment for Resident #99 had missed the obvious skin condition affecting the patient's hands and arms.
The facility's own policy, implemented just four months earlier on April 11, explicitly required licensed or registered nurses to conduct full body skin assessments upon admission and re-admission. The policy mandated weekly follow-up assessments thereafter.
According to the written policy, nursing staff must thoroughly examine residents' skin for conditions including redness. All observations must be documented in the patient record.
The policy language was unambiguous about scope: assessments would be "full body, or head to toe." Highland Manor's nursing staff had clear written direction to examine all skin surfaces and record their findings.
The missed documentation represents more than administrative oversight. Proper skin assessment serves as baseline measurement for tracking changes in patient condition over time. Red, swollen skin can indicate various medical conditions requiring monitoring or treatment.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The citation fell under federal regulation F 0684, which governs comprehensive assessments and care planning.
The inspection report cross-referenced two additional violations - F655 and F658 - suggesting the skin assessment failure connected to broader deficiencies in resident evaluation and care planning processes.
Highland Manor of Fallon operates as a rehabilitation facility, treating patients who typically require close monitoring during recovery periods. Accurate admission assessments establish crucial baseline data for measuring patient progress or decline.
The timing of the policy implementation adds context to the violation. Highland Manor had updated its skin assessment procedures just months before the inspection, suggesting recent recognition of assessment protocol importance.
The April policy revision specified that licensed or registered nurses must personally conduct the assessments, not delegate to lower-level staff. This requirement aimed to ensure qualified professionals evaluated skin conditions and documented findings appropriately.
Despite having clear written procedures in place for less than five months, nursing leadership acknowledged the assessment gap when confronted with specific evidence. The director of nursing's admission suggests awareness of proper protocols alongside failure to implement them consistently.
The violation occurred during a complaint investigation, indicating someone had raised concerns about care quality at Highland Manor. Federal inspectors responded by examining specific aspects of resident assessment and care planning.
Resident #99's red, swollen skin condition was visible enough that inspectors could identify the assessment gap during their review. The obvious nature of the skin changes makes the documentation failure more significant from a care quality perspective.
Highland Manor must now submit a plan of correction detailing how it will prevent similar assessment gaps in the future. The facility faces potential follow-up inspections to verify implementation of corrective measures.
The case illustrates ongoing challenges in nursing home assessment practices, where written policies must translate into consistent bedside implementation. Even recently updated procedures require sustained management attention to ensure compliance.
For Highland Manor's residents and families, the violation raises questions about thoroughness of initial evaluations and ongoing monitoring of patient conditions requiring medical attention.
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 oversight involved Resident #99, whose dry, red, and swollen skin on hands and arms went unrecorded during the admission process on August 27.
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.