SHELTON, WA - State inspectors have identified multiple serious violations at Shelton Health & Rehab Center following a March 19, 2025 inspection, including failures in basic personal hygiene care, critical medical monitoring, and medication management that placed residents at risk for life-threatening complications.
Bathing Care Failures Leave Residents Without Basic Hygiene
The facility failed to provide adequate bathing assistance for five residents, with documentation showing systematic lapses in scheduled hygiene care. One resident reported going nine days without a shower, stating "I have not had a shower yet, I have been nine days, I requested one today." The resident's care plan specified showers twice weekly on Wednesday and Saturday evenings, but facility records showed no documentation of bathing services being provided.
Another resident scheduled for bathing every Thursday and Sunday received only three baths over a 30-day period from mid-February to mid-March 2025. Staff acknowledged that bathing was not consistently offered or provided as scheduled across multiple residents.
Regular bathing serves critical health functions beyond basic cleanliness. Proper hygiene prevents skin breakdown, reduces infection risk, and maintains circulation in vulnerable populations. For elderly residents with limited mobility and compromised immune systems, inadequate bathing can lead to skin infections, pressure ulcers, and increased susceptibility to serious medical complications.
Life-Threatening Medical Monitoring Failures Result in Hospitalization
The most serious violation involved a resident who experienced actual harm when the facility failed to follow physician orders for laboratory monitoring and hydration management. This resident had a complex medical history including kidney problems and required careful monitoring following antibiotic treatment.
After completing a 10-day antibiotic course in November 2024, the resident was placed on an 1,800-milliliter daily fluid restriction and required monitoring. However, records showed the resident consistently failed to meet daily hydration needs for eight of ten days reviewed, consuming as little as 540 milliliters on some days - well below the recommended 1,500 milliliters.
When the resident showed signs of decline on November 22, 2024, the provider ordered critical laboratory tests including a urinalysis, complete blood count, and kidney specialist referral. Despite these orders and documentation that the resident was "on alert for decline," the facility failed to obtain the required tests. No progress notes documented the resident's condition between November 23 and December 1, 2024.
On December 1, the resident was found unresponsive with a fever of 102.5°F, heart rate of 132 beats per minute, and dangerously low blood pressure of 89/59. The resident required emergency hospitalization and intensive care treatment for sepsis, urinary tract infection, and altered mental status.
Laboratory monitoring is essential for detecting early signs of infection and organ dysfunction in vulnerable residents. Urinalysis can identify urinary tract infections before they progress to life-threatening sepsis, while complete blood counts reveal infection markers and organ function changes. When these basic monitoring tools are not utilized as ordered, preventable medical emergencies can occur.
Nutritional Care Deficiencies Cause Severe Weight Loss
Three residents experienced significant nutritional problems due to inadequate monitoring and intervention. One resident lost 14.89% of body weight over six months - from 122.2 pounds to 104 pounds - representing a severe decline that increases mortality risk and compromises immune function.
The facility's Nutritionally Enhanced Meal (NEM) program was improperly implemented. Observations showed residents prescribed NEM diets were not receiving the required whole milk, despite this being a core component of the enhanced nutrition program. Multiple certified nursing assistants stated they didn't understand what NEM meant or what actions it required.
Another resident lost over 11% of body weight in 34 days before staff identified the problem. Despite arriving at the facility with orders for nutritional supplements twice daily, the facility failed to transcribe or implement these orders. When the resident reported loss of appetite and was observed eating 0% of meals, no alternative interventions were provided.
Proper nutrition monitoring requires weekly weights for residents showing decline patterns, accurate meal intake documentation, and prompt intervention when problems are identified. Significant weight loss in elderly residents indicates increased risk for pressure ulcers, infection, delayed wound healing, and increased mortality.
Respiratory Care Equipment Maintenance Problems
Three residents receiving oxygen therapy had compromised equipment that could affect treatment effectiveness. Oxygen concentrator filters were heavily matted with debris, and humidifier bottles remained empty and undated for extended periods. Staff acknowledged they didn't know who was responsible for cleaning filters or replacing humidifier bottles.
Proper oxygen delivery requires clean filters to prevent respiratory irritation and adequate humidification to prevent nasal dryness and airway complications. Contaminated equipment can introduce pathogens into the respiratory system of already vulnerable residents.
Medication Administration and Security Violations
The facility exceeded acceptable medication error rates with a 46.88% error rate during observed medication passes. Multiple residents received medications hours after scheduled times, including critical medications for heart conditions, blood sugar control, and blood clot prevention.
Medication security was compromised when unlabeled pills, insulin pens, and other medications were left unattended on medication carts. One asthma medication remained unavailable for three consecutive days without documented pharmacy contact or provider notification.
Timely medication administration is critical for maintaining therapeutic blood levels and preventing complications. Late administration of heart medications, diabetes treatments, and blood thinners can result in dangerous fluctuations in vital signs and blood chemistry.
Additional Issues Identified
Inspectors documented several other concerning practices including improper infection control procedures, incomplete medical record documentation, and inadequate explanation of arbitration agreements to residents and families. Staff were observed failing to follow standard precautions during wound care and catheter management, potentially spreading infections between residents.
The facility's dialysis care coordination showed gaps in pre- and post-treatment assessments, with missing documentation of medications administered during dialysis sessions. Medical records lacked required documentation for resident deaths and hospital returns, compromising continuity of care.
These systematic failures at Shelton Health & Rehab Center represent fundamental breakdowns in basic nursing home care standards that directly impacted resident health and safety. The violations demonstrate the critical importance of consistent staff training, proper policy implementation, and ongoing quality monitoring in long-term care facilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shelton Health & Rehab Center from 2025-03-19 including all violations, facility responses, and corrective action plans.
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