Shelton Health: Mental Health Screening Failures - WA
State inspectors found the facility failed to complete accurate mental health screenings for three of five residents reviewed during a March inspection. The errors left residents at risk of unmet care needs and diminished quality of life.
Resident 49 arrived at the facility with diagnoses of non-Alzheimer's dementia, psychotic disorder and depression. The resident was taking antipsychotic and antidepressant medications during the assessment period.
But when staff completed the federally required PASRR screening in February, they documented only major depressive disorder. The psychotic disorder diagnosis was missing entirely.
The omission mattered. Federal law requires facilities to conduct Level II evaluations for residents with serious mental illness to determine what specialized services they need. Without the psychotic disorder listed, no referral was made.
Staff F, the Social Services Director, acknowledged on March 18 that the screening was inaccurate and should have included the psychotic disorder diagnosis. A Level II evaluation for serious mental illness was required, she said.
Resident 53 presented an even more complex case. The resident was admitted with major depressive disorder, unspecified psychosis and post-traumatic stress disorder. A February assessment documented the resident as cognitively intact.
The December PASRR screening captured only PTSD. Major depressive disorder and unspecified psychosis were both omitted.
Staff D, a Resident Care Manager, reviewed the screening on March 17 and immediately spotted the missing diagnoses. "That should have been caught," Staff D said when asked about the unspecified psychosis and major depressive disorder.
The Director of Nursing Services, Staff B, confirmed the next day that the PASRR was incorrect and should have been corrected. The resident's actual mental health diagnoses included PTSD, psychosis, insomnia and major depressive disorder.
In the third case, staff made the opposite error. Resident 13's September PASRR screening indicated anxiety disorder, but the resident had no such diagnosis in their electronic health record.
Staff D confirmed during a March 18 interview that anxiety was not on Resident 13's diagnosis list. The Social Services Director acknowledged the following day that the anxiety disorder box should not have been checked.
The screening failures extended beyond mental health assessments into basic care planning. Inspectors found care plans for five residents contained outdated information, missing details or inaccurate instructions that could compromise daily care.
Resident 51 required a chronic indwelling urinary catheter due to neurogenic bladder, a condition documented by providers in January. But the catheter care plan failed to identify why the catheter was needed or address the underlying bladder condition.
"The resident's diagnosis of neurogenic bladder should have been care planned," Staff D said during the March 18 interview.
The same resident had an anxiety monitoring care plan that directed staff to watch for delusions but provided no specifics about what delusions had occurred previously, how they affected the resident, or whether staff should attempt to reorient the person to reality.
Staff D acknowledged the care plan should have been resident-specific and included details about the delusions, their effects and appropriate staff responses.
Resident 41's care plan instructed staff to set up oral care supplies and cue the resident to brush their own teeth. But the resident told inspectors on March 10 they couldn't brush independently because they were right-handed and couldn't lift their arm to their mouth without help.
The quarterly assessment had already documented that Resident 41 required moderate assistance with oral care, meaning staff had to hold or support the resident's limbs while providing less than half the effort.
Staff D said the care plan needed updating to reflect the resident's increased need for physical assistance.
Resident 49's care plan contained multiple inaccuracies. The elopement risk plan stated the resident wore a wander guard on the left wrist, but inspectors found the device attached to the right ankle during their March 10 observation.
The Director of Nursing said the care plan was inaccurate and needed updating.
The same resident had been recommended for nutritionally enhanced meals following a committee review for weight loss. An order was obtained, but the comprehensive care plan contained no documentation of the special diet requirement.
Resident 38's care plan showed conflicting shower schedules. The actual shower record indicated baths on Monday and Thursday day shifts, while the care plan documented Wednesdays.
The most complex care plan problems involved Resident 14, who was severely cognitively impaired and dependent on staff for daily care. The resident's nutrition care plan contained multiple outdated interventions and missing information.
An intervention for house supplements had been initiated in October but was no longer current. A December intervention to offer snacks between meals was never implemented. The plan mentioned a fluid restriction that was a past intervention but wasn't updated to reflect that status.
The care plan noted the resident refused food and fluids but provided no specific interventions for staff to follow when refusals occurred. It didn't mention the resident's significant weight loss or include food preferences that might encourage eating.
Staff D acknowledged that significant weight loss and specific interventions for refusals should have been included in the care plan. During a follow-up interview, Staff D said the facility tried to bring Resident 14 to the dining room for all meals but faced frequent refusals, and snacks were only offered at bedtime.
The Director of Nursing said care plans for residents with significant weight loss should include interventions to stop or slow weight loss and note resident preferences. For Resident 14 specifically, the outdated house supplement intervention should have been removed from the active care plan.
These documentation failures represent more than paperwork problems. PASRR screenings determine whether residents receive specialized mental health services. Care plans guide daily care decisions by nursing assistants and other staff members.
When screenings miss mental illness diagnoses or care plans contain outdated information, residents risk receiving inappropriate care or missing services they need.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Shelton Health and Rehabilitation from 2025-03-19 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
Shelton Health and Rehabilitation in SHELTON, WA was cited for violations during a health inspection on March 19, 2025.
State inspectors found the facility failed to complete accurate mental health screenings for three of five residents reviewed during a March inspection.
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.