Salem Health & Rehabilitation: Wound Care Failures - VA
The violation centered on RN #2, who inspectors determined did not follow established wound care procedures in a way that would promote healing. The specific failures were serious enough that surveyors brought in a reference from Clinical Nursing Skills & Techniques to walk facility leadership through what proper wound care actually looks like, step by step, during a meeting that afternoon.
That reference spelled out a sequence that experienced nurses learn early in their training. Remove the old dressing carefully. Fold soiled gauze inward so the drainage stays contained. Remove gloves inside out over the dressing so contamination doesn't spread. Then, before touching the wound again, perform hand hygiene and put on a fresh pair of gloves. Clean the wound with saline or antiseptic, using a separate gauze or cotton ball for each stroke. Apply any ordered ointment with a sterile applicator. Dispose of gloves. Wash hands again. Then, and only then, apply the new dressing.
The steps exist for a reason. Pressure ulcers, which form when sustained pressure cuts off blood flow to skin and underlying tissue, are among the most serious and preventable complications in nursing home care. They can deepen from surface redness into wounds that reach bone. Infection is a constant risk. Proper technique during each dressing change is one of the few direct interventions that determines whether a wound closes or worsens.
What RN #2 did or did not do during the dressing change was not described in detail in the inspection record. The report identifies the nurse by number, not name, and does not specify which steps were skipped or performed incorrectly. What it does say is that the failure was significant enough to prompt a formal complaint investigation and a deficiency citation.
Inspectors rated the violation at a level of minimal harm or potential for actual harm, a designation that reflects risk rather than confirmed injury. A small number of residents were identified as affected.
The exit conference on August 28 included the facility's administrator, assistant administrator, director of nursing, assistant director of nursing, and regional director of clinical services. Surveyors presented the wound care textbook excerpt directly to that group. No additional information was provided by the facility before inspectors left the building.
Salem Health & Rehabilitation sits at 1945 Roanoke Boulevard in Salem, a city of roughly 25,000 people in the Roanoke Valley. The facility participates in Medicare and Medicaid.
The inspection report does not describe what happened to the resident whose wound was at the center of the complaint. Whether the pressure ulcer healed, worsened, or required additional intervention is not recorded in the document. The resident's name does not appear. Their condition at the time of the inspection, and after, is not known from the public record.
What is known is that someone filed a complaint. Inspectors came. They found what they were looking for.
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: July 1, 2026 · Our methodology
SALEM HEALTH & REHABILITATION in SALEM, VA was cited for violations during a health inspection on August 28, 2025.
The violation centered on RN #2, who inspectors determined did not follow established wound care procedures in a way that would promote healing.
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.