Shelton Health and Rehab: Medication Delays and Gaps - WA
The resident who needed that medication, an inhaler called Breo Ellipta prescribed to treat asthma, had already gone without it for two days. They would go without it again that day. By the time inspectors reviewed the records on March 12, 2025, the medication administration record showed three consecutive days, March 10, March 11, and March 12, with the same notation: "On Order from Pharmacy." No documentation showed anyone had actually contacted the pharmacy. No documentation showed anyone had told the prescribing provider the medication wasn't available.
Staff C, the Resident Care Manager, acknowledged the three-day gap when inspectors sat down with her at 12:27 PM that afternoon. She could not produce a single record showing the pharmacy had been reached. She could not show the provider had been notified. The inhaler was simply gone, and no one had formally escalated it.
That was one resident. The inspection also turned up a separate pattern of late medication administration affecting at least two other residents, identified in the report as Resident 6 and Resident 12.
Resident 12 had been prescribed a combination of medications scheduled for 8:00 AM, including Potassium Chloride and Torsemide, both used to remove excess fluid from the body. Resident 6 was on Gabapentin for pain, Glipizide and Novolin N for blood sugar management, also scheduled at 8:00 AM. Inspectors found these medications were being administered outside the window the facility's own Director of Nursing Services said was acceptable.
Staff B, the Director of Nursing Services, put it plainly when inspectors reviewed the records with her on the afternoon of March 13. Medications should go out either one hour before or one hour after the scheduled time, she said. The late administrations for Resident 6 and Resident 12 did not meet that standard. "This did not meet expectations," she told inspectors at 3:18 PM.
She said it without apparent dispute. The violations were not contested in the inspection record. They were acknowledged, named, and left on the page.
The medications involved in the late administration findings are not incidental drugs. Glipizide and Novolin N manage blood sugar in diabetic patients, where timing affects how the body processes glucose across the day. Torsemide and Potassium Chloride work in tandem to reduce fluid buildup, a condition that can affect the heart and lungs when poorly managed. Gabapentin, prescribed for pain, works on a schedule. None of these medications are designed to be given whenever staff gets around to it.
The omitted inhaler raises a different kind of concern. Breo Ellipta is a maintenance medication for chronic obstructive pulmonary or asthmatic conditions, not a rescue inhaler used during acute episodes. It works through daily, consistent use. Missing one day interrupts that consistency. Missing three in a row, with no provider notified and no documented effort to reorder, is a different failure entirely.
The inspection, completed March 19, 2025, assigned a harm level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework inspectors use to score deficiencies. It does not describe what three mornings looked like for the resident who reached for an inhaler that wasn't there, or what it means to have fluid-management medications arrive late when your body is working to compensate for what it cannot clear on its own.
Staff S, the Licensed Practical Nurse observed during medication pass on March 12, found the empty drawer, said what she said, and the visit continued. The resident's chart showed the gap. The Resident Care Manager confirmed it. The pharmacy had not been called.
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 4, 2026 · Our methodology
Shelton Health and Rehabilitation in SHELTON, WA was cited for violations during a health inspection on March 19, 2025.
The resident who needed that medication, an inhaler called Breo Ellipta prescribed to treat asthma, had already gone without it for two days.
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.