Shelton Health and Rehab: Oxygen Equipment Failures - WA
That was the answer inspectors got when they asked Staff O, a nurse at the facility, to describe what the filter looked like. "Dirty," she said first. Then: "I didn't even know that was there. I don't know who is supposed to clean it. I don't think we nurses do that."
A second registered nurse, identified in the inspection report as Staff R, said the same thing. Nursing, she believed, was not responsible for cleaning the external filters on the oxygen concentrators.
The Director of Nursing told inspectors on March 14 that staff should in fact be cleaning those filters weekly, and more often as needed. Nobody had been doing it.
Oxygen concentrators pull room air through external filters before processing it and delivering oxygen to a patient. When those filters go uncleaned, the machine works harder and delivers less. For residents already dependent on supplemental oxygen to maintain safe blood oxygen levels, the equipment's performance is not a minor detail.
The filter problem was one of two oxygen-related failures inspectors documented during the March 19 survey.
The second involved a humidifier bottle, the small water reservoir attached to an oxygen concentrator that adds moisture to the oxygen stream before it reaches a patient's nose. Dry supplemental oxygen delivered through a nasal cannula for extended periods can irritate and damage airway tissue. The humidifier bottle is supposed to prevent that.
Inspectors observed Resident 38 on two separate occasions, on March 10 at 2:32 in the afternoon and again on March 11 at 11:41 in the morning, lying in bed receiving oxygen through a nasal cannula. Both times, the humidifier bottle on the concentrator was empty. It was also undated, meaning there was no way to tell when it had last been checked or changed.
Resident 38 had a physician's order, written in November 2024, directing staff to deliver oxygen at levels between zero and five liters per minute, targeting a blood oxygen saturation above 92 percent. The order also directed staff to contact the provider if the resident was receiving three liters per minute or more. On the days inspectors observed, Resident 38 was receiving two liters per minute, placing them just below that threshold.
What the chart did not contain was any order or direction to check the humidifier bottle, or to replace it. No one had written it down as a task. No one, apparently, had been doing it.
On March 11, the afternoon after inspectors' second observation of the empty bottle, the facility's Resident Care Manager, Staff C, confirmed what inspectors had seen. The bottle was empty. It needed to be replaced.
The inspection report notes minimal harm or potential for actual harm, with some residents affected. That classification reflects the regulatory framework inspectors use to categorize deficiencies. It does not mean nothing was wrong with breathing dry oxygen through equipment no one knew needed maintenance.
What the inspection captured, across three separate staff interviews and two days of observation, was a facility where the most basic questions about oxygen equipment had no clear answers. Who cleans the filter? Nobody knew. Who checks the humidifier bottle? There was no order for it. Who is responsible? The nurses didn't think it was them.
The Director of Nursing, when finally asked, knew the answer. Weekly cleaning, more often as needed. Whether anyone had communicated that to the nurses actually working with the equipment, the inspection report does not say.
Resident 38 spent at least two days receiving oxygen through a concentrator with an empty humidifier bottle. How many days before inspectors arrived the bottle had been empty, no one said.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 4, 2026 · Our methodology
Shelton Health and Rehabilitation in SHELTON, WA was cited for violations during a health inspection on March 19, 2025.
That was the answer inspectors got when they asked Staff O, a nurse at the facility, to describe what the filter looked like.
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.