Shelton Health and Rehabilitation: Diagnosis Error - WA
The form in question was a Level I PASRR, a federally required pre-admission screening used to determine whether a nursing home resident needs specialized mental health or intellectual disability services. Getting it wrong matters. The form shapes what services a resident is offered and what follow-up evaluations get triggered.
For Resident 13, the form was completed on September 12, 2024. Someone checked the box for anxiety disorder.
The resident did not have anxiety disorder. It was not on their diagnosis list. The electronic health record made that clear.
When inspectors reviewed the case on March 18, 2025, the facility's Resident Care Manager confirmed what the health record showed: Resident 13 did not have anxiety on their diagnosis list. The next day, the facility's Social Services Director acknowledged the box should not have been checked.
That was six months after the form was submitted.
The inspection, conducted on March 19, 2025, rated the violation as causing minimal harm or potential for actual harm, and noted that only a few residents were affected. Those classifications sit at the lower end of the federal deficiency scale. No immediate jeopardy was cited. No pattern of similar errors was documented in this report.
But the PASRR process exists for a reason. Federal and state rules require nursing homes to screen residents for mental illness and intellectual disabilities before or shortly after admission, precisely because those conditions require specific care planning and, in some cases, referral for specialized services. A resident screened as having anxiety disorder when they do not could be steered toward evaluations or interventions they don't need. A resident whose actual conditions are overlooked on that same form could be steered away from services they do.
The error here was not caught by any internal review. It surfaced because inspectors looked.
Staff D, identified in the report by the title RCM, said plainly during the March 18 interview that anxiety was not among the resident's diagnoses. Staff F, the SSD, said the following day that the box should not have been checked. Neither account suggested any prior awareness of the discrepancy or any effort to correct the form before the inspection.
Shelton Health and Rehabilitation is located at 153 Johns Court in Shelton, Washington. The inspection was completed March 19, 2025.
The facility was cited under WAC 388-97-1915, Washington State's administrative code governing PASRR requirements for nursing facilities.
A plan of correction was not included in the inspection materials reviewed. The report directs anyone seeking that information to contact the facility or the state survey agency directly.
What the inspection does not answer is whether anyone reviewed Resident 13's care plan after the form was filed, whether the incorrect anxiety diagnosis influenced any clinical decisions in the months between September 2024 and March 2025, or whether the resident was ever told what had been submitted on their behalf.
The form said one thing. The record said another. Six months passed.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
Shelton Health and Rehabilitation in SHELTON, WA was cited for violations during a health inspection on March 19, 2025.
The form shapes what services a resident is offered and what follow-up evaluations get triggered.
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.