Salem Health: Diabetic Left Without Insulin - VA
State inspectors found no documentation that staff checked Resident #6's blood glucose levels or administered Novolog insulin on August 15, 16, 20, 24, and 25. The resident was supposed to receive 15 units of insulin before meals and at bedtime, plus additional doses based on blood sugar readings.
The 77-year-old resident suffered from Type 2 diabetes, heart disease, chronic obstructive pulmonary disease, and cognitive impairment. A mental status assessment in August showed the resident scored 11 out of 15 points, indicating moderate cognitive impairment that would make self-advocacy difficult.
Medical orders from April required staff to inject 15 units of Novolog subcutaneously before meals and at bedtime. A separate sliding scale order detailed additional insulin doses based on blood sugar levels, ranging from zero units for readings between 61-199 to 16 units for readings above 500.
The facility's medication administration record for August showed blank entries where insulin doses should have been documented. Staff had not marked the medication as given, refused by the resident, or held for medical reasons.
Nobody had checked the resident's blood sugar at 6 a.m., 4 p.m., or 9 p.m. on August 15. The morning blood glucose check was also missing on August 16, 20, 24, and 25.
The resident's care plan specifically identified diabetes management as a priority. One section warned the resident was "at risk for complications and blood glucose fluctuations related to diagnosis of diabetes mellitus with insulin use." The plan called for staff to "administer medications as ordered."
Another section of the care plan noted the resident was at risk for low blood sugar complications from diabetes medications. Staff were supposed to "monitor for signs and symptoms of hypoglycemia" and take vital signs as needed.
When confronted by inspectors on August 27, the director of nursing said she would investigate why the medication wasn't given. After reviewing records, she told inspectors she "could not find any evidence of the Novolog being held, given, or refused by the resident on the days that were blank on the August 2025 MAR."
The facility's own medication policy required nurses to check orders and vital signs before giving medications. The policy made no exceptions for insulin or other critical medications.
During the inspection's exit meeting on August 28, administrators, nursing directors, and a regional clinical services director discussed the violation. No additional documentation explaining the missed insulin doses was provided to inspectors before they completed their review.
The missed medications occurred over a 10-day period in August, with gaps appearing on both weekdays and weekends. The pattern suggested systemic problems with medication administration rather than isolated oversights.
For diabetics, missing insulin doses can cause blood sugar to spike dangerously high, leading to complications including dehydration, organ damage, and potentially life-threatening ketoacidosis. The resident's sliding scale orders anticipated blood sugar readings as high as 500 or more, indicating previous episodes of poor glucose control.
The facility cared for other residents with diabetes and medication management needs, but inspectors found this particular failure affected only Resident #6 among the 10 residents they sampled during the complaint investigation.
Federal regulations require nursing homes to provide treatment and care according to physician orders and professional standards. The violation was classified as causing minimal harm or potential for actual harm, though diabetes experts consider consistent insulin administration critical for preventing serious complications.
Salem Health & Rehabilitation operates as a 120-bed facility on Roanoke Boulevard. The August inspection was conducted in response to a complaint, though inspectors did not detail the nature of the original concerns that prompted their visit.
The resident remained at the facility during the inspection period, continuing to require multiple daily insulin injections and blood sugar monitoring to manage the chronic condition that affects nearly 30 million Americans.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Salem Health & Rehabilitation from 2025-08-28 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
SALEM HEALTH & REHABILITATION in SALEM, VA was cited for violations during a health inspection on August 28, 2025.
State inspectors found no documentation that staff checked Resident #6's blood glucose levels or administered Novolog insulin on August 15, 16, 20, 24, and 25.
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.