Salem Health & Rehabilitation: Infection Control Failures - VA
The infection control violation occurred on August 28 during what should have been routine wound care for a resident with an ischium injury at Salem Health & Rehabilitation.
Licensed Practical Nurse #10 carried the multiuse bottle of Dakins Solution into the resident's room in a clean plastic bag. But the precautions ended there.
The nurse removed the solution container and placed it directly on the resident's overbed table without cleaning the surface first. After completing the dressing change, she picked up the bottle and set it directly on the roommate's fabric chair seat cushion while washing her hands.
The nurse then returned the contaminated bottle to the unit treatment cart, placing it in the bottom drawer among other medical supplies without sanitizing it.
Federal inspectors observed the entire sequence during their complaint investigation. The multiuse nature of the Dakins Solution meant the contamination could affect multiple residents who would receive wound care with the same bottle.
When confronted about the observations, the facility's Infection Preventionist acknowledged the violation. He told inspectors the solution should have remained in a zip lock bag inside the treatment cart and said he would discard the contaminated bottle.
The Infection Preventionist promised to get a new bottle for the resident and store it properly in the treatment cart.
Dakins Solution is a diluted bleach solution commonly used to clean infected wounds and prevent bacterial growth. Proper infection control requires keeping the solution sterile and preventing cross-contamination between residents.
The contamination chain the nurse created was extensive. The overbed table, used for meals and personal items, had not been cleaned before the medical bottle touched its surface. The roommate's fabric chair cushion then absorbed whatever contaminants the bottle had picked up.
By the time the bottle returned to the treatment cart, it had been exposed to multiple unsterile surfaces. Other medical supplies in the drawer faced contamination from contact with the bottle.
The violation occurred despite the nurse initially following proper protocol by transporting the solution in a clean bag. The breakdown happened during the actual procedure when convenience apparently trumped infection control.
Fabric surfaces like chair cushions pose particular infection risks in healthcare settings because they cannot be easily disinfected and can harbor bacteria for extended periods.
The inspection team met with facility leadership at 4:00 PM on the day of the violation. Present were the administrator, assistant administrator, director of nursing, assistant director of nursing, and regional director of clinical services.
No additional information about the infection control failures was provided before inspectors concluded their investigation.
The violation was classified as causing minimal harm or potential for actual harm to few residents. However, the multiuse nature of the contaminated solution meant the risk extended beyond the single resident receiving wound care.
Salem Health & Rehabilitation had no immediate response to the infection control breakdown. The facility provided no explanation for why established protocols were not followed during the observed wound care procedure.
The contamination incident highlights how quickly infection control measures can break down during routine medical procedures. A single nurse's decision to place a medical bottle on contaminated surfaces created potential exposure risks for multiple residents.
The Infection Preventionist's immediate decision to discard the contaminated solution suggests facility leadership recognized the seriousness of the violation once confronted with the inspector's observations.
Federal regulations require nursing homes to maintain strict infection control protocols to protect vulnerable elderly residents from healthcare-associated infections. The observed violations represent a fundamental breakdown in these protective measures.
The incident occurred during a complaint investigation, suggesting ongoing concerns about care quality at the Salem facility prompted the federal inspection visit.
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 21, 2026 · Our methodology
SALEM HEALTH & REHABILITATION in SALEM, VA was cited for violations during a health inspection on August 28, 2025.
Licensed Practical Nurse #10 carried the multiuse bottle of Dakins Solution into the resident's room in a clean plastic bag.
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.