Shelton Health and Rehabilitation: Infection Control Failures - WA
That observation, made on March 11, 2025, was one of several instances inspectors documented in which staff skipped basic protective equipment during direct care — wound treatment, catheter care, a lunch delivery to a resident on contact precautions — at the 153 Johns Court facility.
The nurse, identified in the report as Staff R, wiped the resident's upper arm with an alcohol swab and injected insulin without gloves. When asked about it more than two hours later, she said: "I wash my hands regularly, so I have never known there to be a reason to wear gloves for an injection of any kind."
The resident, identified as Resident 12, was cognitively intact, according to a February assessment. She had been prescribed Novolin N FlexPen, two units injected twice daily into the fatty tissue layer beneath the skin.
The facility's own managers said the bare-handed injection fell short. Staff C, the Resident Care Manager, said the observation "did not meet his expectations." Staff B, the Director of Nursing Services, confirmed the same the following day: her expectation was that staff put on gloves for insulin administration.
The gap between what managers expected and what staff actually did showed up repeatedly across the inspection.
On March 10, a staff member identified as Staff U delivered a lunch tray to Resident 4, a patient whose door was posted with a contact precautions sign. Staff U entered the room without a gown or gloves, touched the resident's water pitcher, and cut up their food. A passing nurse noticed and called out that Staff U had not gowned up. Staff U washed her hands with soap and water and put on PPE — but only after the contact had already happened.
The most extended breakdown in infection control involved Resident 13, a patient receiving wound care on their right heel and urinary catheter care. Inspectors watched as Staff M performed the wound care while wearing gloves but no gown, despite the room being designated for enhanced barrier precautions. After finishing, Staff M touched the trash can, grabbed a pillow and repositioned it under the resident's legs, removed their gloves, touched their own scrub bottoms, picked up scissors and tucked them into their scrubs, and then walked to the sink to wash their hands.
The sequence continued. Still with bare hands, Staff M took the trash out of the room, grabbed wound cleanser from the bedside, put it back on the tray, lined the trash can with a new bag, put wipes into the resident's drawer, and then carried the wound cleanser — now contaminated — out of the room and placed it on the treatment cart in the hallway.
The Director of Nursing, Staff B, reviewed the sequence item by item with inspectors. The missing gown during wound and catheter care did not meet expectations. The failure to perform hand hygiene with every glove change did not meet expectations. Leaving the resident's uncovered wound resting in a padded heel protector without any barrier did not meet expectations. Taking the contaminated wound cleanser out of the room and onto the shared treatment cart did not meet expectations.
"The wound cleanser should have been left in the resident's room," Staff B said.
Contact precaution rooms and enhanced barrier precaution rooms exist for a reason: the residents inside them carry infections or wounds that can spread. The protocols are not complicated. Gown and glove before entering. Change gloves between tasks. Wash hands. Keep contaminated supplies contained. What inspectors found at Shelton Health and Rehabilitation was staff who either did not know those steps or did not take them — and a management team that learned about each failure only when investigators arrived to ask.
Resident 12, cognitively intact and aware of everything happening around her, received her insulin injection from a nurse who had never thought gloves were necessary.
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.
The nurse, identified in the report as Staff R, wiped the resident's upper arm with an alcohol swab and injected insulin without gloves.
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.