Highland Manor of Fallon Rehabilitation LLC

In the surveyor’s words

From the most serious findings on record at Highland Manor of Fallon Rehabilitation LLC, in the surveyor’s own words.

• Actual harm, isolatedF600Sep 4, 2025

  Based on observation, interviews, clinical record review, and document review, the facility failed to 1) ensure that 1 of 4 residents (Resident #97) investigated for abuse and/or neglect received the necessary care and services to prevent a wound from deteriorating and becoming infected, resulting in the resident requiring emergent care for sepsis at an acute care hospital, where the resident subsequently expired due to sepsis and 2) protect residents' right to be free from neglect when signs and symptoms of infection and a change in skin condition in 1 of 18 sampled residents (Resident #24) were not reported timely to the physician by a Licensed Practical Nurse (LPN), resulting in the resident experiencing testicular pain and swelling and developing an infection that required intravenous… […]

• Actual harm, isolatedF760Nov 12, 2024

  Based on interview, clinical record review, and document review, the facility failed to ensure a significant medication error did not occur when a resident was administered a penicillin antibiotic when the resident had a known penicillin allergy for 1 of 7 sampled residents (Resident #1). This deficient practice resulted in the resident being hospitalized after developing symptoms of an allergic reaction. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including colostomy status, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and Alzheimer's disease, unspecified. […]

• No harm, potential for more than minimal, widespreadF641Sep 4, 2025

  Based on clinical record review, personnel record review, document review, and interviews, the facility failed to 1) ensure that Minimum Data Set (MDS) 3.0 Resident Assessments for 16 of 18 sampled residents (Resident #3, #4, #7, #23, #24, #42, #78, #90, #99, #101, #5, #9, #10, #21, #34, and #84) accurately reflected each resident's status and were completed with appropriate participation from qualified health professionals, 2) ensure the MDS assessment was completed accurately for 1 of 18 sampled residents (Resident #34). […]

• No harm, potential for more than minimal, widespreadF868Aug 22, 2024

  Based on interview, and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee held meetings quarterly at a minimum. This failure had the potential to result in the facility not identifying and addressing concerns related to the quality of care in all areas of the facility. Findings include: The QAPI sign in sheets documented all required committee members were in attendance during the 4th quarter 2023, with the last meeting held on 09/20/2023. The facility lacked documented evidence of a meeting being held from January 2024 through June 2024. On 08/22/2024 at 1:56 PM, the Administrator verbalized the committee would meet as often as needed and at a minimum quarterly. […]

• No harm, potential for more than minimal, widespreadF880Aug 22, 2024

  Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) the facility had a surveillance plan for identifying and tracking all infections in the facility. This deficient practice had the potential to result in the unmitigated spread of infections within the facility, 2) staff providing wound care to a resident on Enhanced Barrier Precautions (EBP) wore the appropriate Personal Protective Equipment (PPE) for 1 of 19 sampled residents (Resident #52), 3) staff changing a resident's ileostomy bag donned gloves and washed hands for 1 of 19 sampled residents (Resident #134), and 4) to ensure a resident's humidifier attached to the oxygen concentrator was not placed on the ground for 1 of 19 sampled residents (Resident #32). […]