Salem West Healthcare: Untreated Foot Wounds - OH
The resident arrived at the facility in October after losing his right great toe. Within ten days, he was screaming in his room, saying he wanted to kill himself and throwing items at staff before being sent to the hospital.
When he returned on October 31, nurses documented a one-inch dark scab with no drainage on top of his right foot and noted a dry dressing in place. But no physician's orders existed for any foot treatment.
Staff continued applying foam dressings anyway.
On November 3, inspectors found the resident sitting at the nurses station with a border foam dressing on his right foot dated November 1. Licensed Practical Nurse #101 said she didn't know why the dressing was there. She checked the orders and confirmed no order existed for a foot dressing.
The Regional Director of Clinical Operations told inspectors the next day that staff had placed the dressing as "pad and protect" after notifying the nurse practitioner on November 1. But the nurse never entered the order into the computer system.
She insisted the resident had no open areas or scabbed areas on his right foot. Staff would have caught any problems during his weekly skin check, she said.
The inspection revealed otherwise.
When the Director of Nursing and regional clinical director removed the dressing on November 4, inspectors observed a dime-sized scabbed area on top of his foot near the second toe. Three pea-sized scabs covered the top of his second toe.
The Director of Nursing said they provided no treatment to the scabs because they were "closed wounds."
The resident had been admitted with diabetes, dementia, bacteremia, chronic obstructive pulmonary disease, hypertension, anxiety disorder, depression, Alzheimer's disease, intermittent explosive disorder, dysphagia, and absence of part of his right foot. His admission assessment noted moderately impaired cognition.
Emergency medical technicians had transported him from the hospital via ambulance in October. Nurses performed a head-to-toe assessment and documented that he had lost his right great toe.
His October hospitalization followed an incident where he was found screaming in his room, threatening suicide and unable to calm down while throwing items at staff.
Upon his return, nurses noted the dark scab and dry dressing but failed to obtain treatment orders. The November physician's orders contained no instructions for right foot treatment. The November Treatment Administration Record showed no documentation of any foot treatments.
For three days, staff applied foam dressings to his foot without medical authorization. The November 1 dressing remained in place when inspectors arrived November 3, with the licensed practical nurse unable to explain its presence.
Only when the regional clinical director and Director of Nursing removed the dressing in front of inspectors did they discover the multiple scabs requiring treatment. The resident had been walking around for days with untreated wounds on his diabetic foot while staff provided unauthorized care.
The facility's failure affected one of three residents reviewed for wound care during the complaint investigation. Inspectors classified the violation as minimal harm or potential for actual harm.
State regulations require nursing homes to provide appropriate treatment and care according to physician orders, resident preferences and goals. Salem West Healthcare Center failed to obtain proper orders before treating the diabetic resident's foot wounds, then failed to recognize the scabs required medical treatment.
The resident's complex medical conditions, including diabetes and cognitive impairment, made proper wound monitoring critical. Instead, he received days of unauthorized treatment while actual wounds went unaddressed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Salem West Healthcare Center from 2025-08-25 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 21, 2026 · Our methodology
SALEM WEST HEALTHCARE CENTER in SALEM, OH was cited for violations during a health inspection on August 25, 2025.
The resident arrived at the facility in October after losing his right great toe.
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.