Shelton Health and Rehabilitation: Medication Tracking Failures - WA
That was the finding inspectors documented at Shelton Health and Rehabilitation in mid-March, after reviewing the care of Resident 163, a dialysis patient whose medication records had gone untracked for days. The resident was prescribed Ceftazidime, an antibiotic, along with midodrine, a blood pressure medication. Both were to be administered at the dialysis center. Nurses at Shelton had confirmed only one dose of one drug. The antibiotic was unaccounted for entirely.
The Director of Nursing Services, identified in the inspection report as Staff B, told inspectors on March 17 that she did not see documentation showing the resident received Ceftazidime at dialysis on any date it was ordered. "Staff B said they did not know if Resident 163 received Ceftazidime when it was ordered to be received at dialysis," the report states.
The problem wasn't just one missed dose. It was the system, or the absence of one.
When Resident 163 returned from dialysis sessions, floor nurses were not following up with DaVita, the dialysis provider, to confirm what had happened during the visit. No one was checking what medications had been given, what the resident's condition was, or what the dialysis center needed the nursing home to know. Staff C, a nurse manager, told inspectors that the expectation was that Resident 163 would carry a form to dialysis and bring information back. In practice, that handoff wasn't happening, and nobody had noticed until inspectors asked.
The gap had been visible in the records for at least ten days before anyone moved to close it.
On March 7, a progress note documented that the resident had gone to dialysis. That same note raised a question about shower scheduling, using the phrase "no showers," which Staff C told inspectors they did not understand. "I don't know," Staff C said when asked what it meant. "I will have to call and find out." Staff C called DaVita later that morning and learned the phrase referred to a restriction on shower days tied to dialysis. They said they would update the care plan.
By 1:27 PM that same day, Staff C acknowledged the information about showers and medications had not been clarified on the 7th, and said it should have been reviewed by nurse management when it was first noticed.
A pre-dialysis evaluation for March 10 was also missing. Staff B told inspectors she did not see one in the record and said it should have been completed by a nurse before the resident left for that session.
By March 17, the facility was still trying to piece together what had occurred. Staff C said the floor nurse had not been following up with DaVita after dialysis visits, and that the nurse manager had contacted DaVita that day to request medication records for the resident, so the facility could have them on file. Staff B said the RCM was also calling to obtain that information.
The inspection was completed March 19. CMS cited the facility under Washington state regulation WAC 388-97-1900, which covers care planning and coordination of services. The violation was tagged at a level of minimal harm or potential for actual harm, affecting a small number of residents.
What the record doesn't show is whether Resident 163 received the antibiotic at all during the days it was ordered, or what, if any, clinical consequences followed from the gap. The Director of Nursing said she didn't know. As of the inspection date, the facility was still waiting for DaVita to tell them.
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.
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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 resident was prescribed Ceftazidime, an antibiotic, along with midodrine, a blood pressure medication.
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.