Shelton Health And Rehabilitation
Shelton Health and Rehabilitation in SHELTON, WA — inspection on March 19, 2025.
Found 18 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on interview and record review, the facility failed to ensure the transfer of funds, from a
(Residents 165 and 166) reviewed for resident trust.
This failure placed the resident and/or their representatives at risk for loss of funds and the interest accumulated.
Findings included .
A review of the electronic medical record showed Resident 165 discharged on [DATE] and a review of their account showed it contained a balance of $40.00.
On [DATE] at 12:51 PM, Staff Q, Business Office Manager, said Resident 165's account was closed on [DATE].
A review of the electronic medical record showed Resident 166 died on [DATE] and a review of their account showed it contained a balance of $189.51.
On [DATE] at 12:51 PM, Staff Q, Business Office Manager, said Resident 166's account was closed on [DATE].
On [DATE] at 2:00 PM, Staff A, Administrator, acknowledged the resident's accounts were not closed within 30 days of their discharge and said the expectation was for the checks to be issues timely within 30 days.
Reference WAC 388-97-0340(4)(5) .
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
Findings included . Resident 18 admitted to the facility on [DATE].
The Quarterly Minimum Data Set (an assessment tool), dated 01/15/2025, documented Resident 18 was cognitively intact. Resident 18 had diagnoses of bipolar disorder (mood swings ranging from depressive lows to manic highs), borderline personality disorder (unstable moods, behaviors, and relationships), major depressive disorder (Depression) and unspecified dementia (thinking and social symptoms that interfere with daily functioning).
On 03/11/2025 at 9:43 AM, Resident 18 reported that after a fall they thought was approximately 7-8 weeks ago, a nurse had told them to get up and that Resident 18 had said they had just had surgery and could not. Resident 18 said the nurse had pushed their bed remote to make them sit up straight and was so mean. Resident 18 was unsure of the nurse's name. Resident 18 became tearful and said they did not tell anyone at the time as they were afraid they would be in trouble.
At 11:02 AM, Staff B, Director of Nursing Services (DNS), was made aware of Resident 18's allegation.
Review of a Nursing progress note, dated 07/20/2024, documented Pt [patient] educated on repositioning in bed to reduce the discomfort/pain [Resident 18] c/o [complains of] to Left shoulder, back and right hip. Pt takes education as a personal attack on [Resident 18].
When educating and showing [Resident 18] bed positioning to improve wellbeing, pt turns everything around and states to why [Resident 18] can't position that way in bed. Pt stated to kitchen staff passing snacks that this writer was being mean to [Resident 18] and not allowing [Resident 18] to lay in bed the way [Resident 18] wants to.
Review of the 07/2024 Accident and Incident log showed no entry regarding the above incident.
On 03/17/2025 at 12:24 PM, Staff B, DNS, said the 07/20/2024 Nursing progress note was likely referring to the incident that Resident 18 had described.
Staff B said the incident should have been reported at the time so it could have been investigated.
On 03/18/2025 at 3:08 PM, Staff A, Administrator, said their expectation was for the documented incident to have been reported by staff at the time it happened so an investigation could have been done.
Reference WAC 388-97-0640(5)(a) .
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Findings included . 1) Resident 7 was admitted to the facility on [DATE]. Resident 7 transferred to the hospital on [DATE] and returned to the facility on [DATE]. 2) Resident 14 was admitted to the facility on [DATE]. Resident 14 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 14 was transferred to the hospital on [DATE] and returned to the facility on [DATE]. Resident 14 was transferred to the hospital on [DATE] and returned to the facility on [DATE].
On 03/18/2025 at 11:16 AM, Staff F, Social Services Director, said the process for hospitalizations included obtaining the transfer notice, the bed hold and the monthly audit sheet for each resident transferred during the previous month.
Staff F said they would send an email to the Ombudsman the first week of the month, for the previous month, that included the transfer notice, the bed hold notice and the monthly audit log.
Staff F was unable to locate the May 2024 audit log for Resident 7.
Review of the December 2024 audit log showed Resident 14 was not on the December 2024 audit log.
Staff F confirmed Resident 14 was not on the audit log.
Staff F said prior to January 2025, they had been faxing the transfer paperwork to the Ombudsman, but had no way to show Resident 14's transfer documentation had been faxed to the Ombudsman.
Reference WAC 388-97-0120 (2)(a-d) .
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
During an interview on 03/18/2025 at 12:11 PM, Staff D, RCM, said Resident 13 did not have anxiety on their diagnosis list.
During an interview on 03/19/2025 at 4:48 PM, Staff F, SSD, acknowledged the box for anxiety disorder should not have been checked for Resident 13.
Reference WAC 388-97-1915 (1)(2)(a-c) .
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
During an interview on 03/18/2025 at 2:04 PM, Staff B, DNS, when asked their expectation for care
the resident preferred the dining room.
When asked if they expected interventions and how they worked in the care plan, said at times.
Staff B said they did not expect all preferences on the care plan, but that the care plan could include if the resident liked chocolate over vanilla.
Regarding Resident 14, Staff B said the care plan should have been updated to have removed the house supplement as an active intervention.
Reference F-F692, F-F641 Reference WAC 388-97 -1020(2)(c)(d),(5)(b) .
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
Review of Resident 14's shower log on 03/14/2025, showed their last shower was on 02/24/2025.
During an interview on 03/14/2025 at 11:16 AM, Staff D, RCM, looked in the EHR and the shower binders, and said as far as they could tell, Resident 14 had not had a shower since 02/24/2025.
Staff D said Resident 14 was to get showers on Monday and Thursdays.
During an interview on 03/17/2025 at 4:43 PM, Staff B, DNS, said their expectation was for the resident be bathed per preference.
Staff B said it did not meet expectations that Resident 14, when reviewed on 03/14/2025, had not had a shower since 02/24/2025.
Reference WAC 388-97-1060 (2)(c) .
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
Review of the February 2025 MAR showed Resident 49 was not administered Milk of Magnesia on the fourth day without a bowel movement as ordered.
On 03/18/2025 at 8:33 AM, Staff B, DNS, said the nurse should have administered Resident 49's Milk of Magnesia on 02/19/2025 as ordered, but failed to do so.
Reference WAC 388-97-1060 (1) .
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
Resident 29 had just recently triggered for weight loss and they did not know if it had been struck out
with thin liquids and NEM. Resident 29 was also receiving a calorie supplement.
When observation of
29 should have received the NEM diet and the meal card should reflect the correct diet type to include NEM.
On 03/17/2025 at 2:38 PM, Staff D, RCM, with Staff C, RCM, present, said the process for when a resident has been identified as losing weight included bringing the concerns to the weekly nutrition meeting.
Staff, including the Registered Dietitain, would make recommendations, review current interventions and complete a new assessment for the resident.
Staff C said it also included notifying the family and provider of the resident's weight loss.
When asked about Resident 29's weight loss, Staff D said Resident 29 was not triggered for weight loss.
Staff D was shown Resident 29's weight loss calculations, Staff D said they were not aware Resident 29 had lost weight.
Staff D confirmed there were no progress notes or current evaluations completed for Resident 29's weight loss.
Staff D said Resident 29 was on regular diet with thin liquids with NEM.
Staff D said staff should be offering Resident 29 an alternative meal or supplements if the resident ate less than 50% of the meal.
Staff D said it was the responsibility of the RCMs to ensure residents received the correct diet that matched the meal card.
March 13th and 17th observations were explained about no NEM diet on meal card and no staff had offered Resident 29 an alternative meal.
Staff D said it was the expectation that residents received the correct diet, and staff would offer an alternative meal.
On 03/18/2025 at 12:53 PM, when asked about Resident 29's weight loss, Staff B, DNS, with Staff E, Divisional Director/Regional RN present, said they were aware Resident 29 had lost some weight over the past year and had been trending down recently.
Staff B said Resident 29 was on a regular, regular diet with thin liquids and NEM.
Staff B said the NEM diet should have been documented on the meal card.
Staff B said they provided documentation of Resident 29 being offered alternative meal, the Nutrition-Meal Monitor Follow Up Question Report.
When asked about the observations that no staff had offered an alternative meal to Resident 29, Staff B said an alternative meal was offered, surveyor just didn't observe it.
Reference WAC 388-97 -1060 (3)(h) .
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
Review of the EHR showed a 11/06/2024 order for O2 at 0-5 L/min to keep SpO2 greater than 92%. If receiving 3L/min or greater contact the provider.
On 03/10/2025 at 2:32 PM and 03/11/2025 at 11:41 AM, Resident 38 was lying in bed receiving O2 at 2L/min via NC.
Observation of the O2 concentrator showed the humidifier bottle was empty and undated.
Review of Resident 38's physicians' orders and March 2025 MAR showed there was no order for, or direction to, check/replace the humidifier bottle.
On 03/11/2025 at 2:45 PM, Staff C, RCM, confirmed the humidifier bottle was empty and needed to be replaced.
On 03/14/2025 at 3:20 PM, Staff B, Director of Nursing, said staff should be cleaning the O2 concentrator external filters weekly and as needed.
Reference WAC 388-97-1060 (3)(j)(vi) .
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
found a progress note stating the resident went to dialysis that day.
When Staff C was asked what no
At 11:11 AM, Staff C said they called Davita Dialysis this day and no showers means no showers on
showers days from Wednesday.
At 1:27 PM, Staff C said the information from dialysis, regarding showers and medication, was not clarified on the 7th.
Staff C said the information should have been reviewed by nurse management when it was noticed.
On 03/17/2025 at 1:33 PM, Staff C said Resident 163 should take a form with them to dialysis and they should get information back from the dialysis center.
The information received should be looked at by the nurse and if there was something for the doctor, the doctor should be notified.
When asked if Resident 163 received their Ceftazidime and midodrine at dialysis, Staff C said, we only know [Resident 163] received midodrine on the 7th.
Staff C said the floor nurse was not following up with Davita when Resident 163 returned from dialysis.
Staff C said they had contacted Davita, requesting information on the medications Resident 163 received while at dialysis, so they would have it for their records.
On 03/17/2025 at 2:17 PM, Staff B, Director of Nursing Services, said they did not see a pre-dialysis evaluation for the 10th and it should have been completed by the nurse.
Staff B said they did not see any documentation that the resident received medications at dialysis except on the 7th.
Staff B said they did not know if Resident 163 received Ceftazidime when it was ordered to be received at dialysis.
Staff B said the expectation was Resident 163 would have a list of what occurred at dialysis and that we would communicate with them, and they would communicate with us.
Staff B said the RCM was calling to get that information.
Reference WAC 388-97-1900 (1), (6)(a-c) .
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
Review of Resident 57's Medication Administration Record (MAR) for 03/10/2025, 03/11/2025 and 03/12/2025 showed Breo Ellipta was not administered on those days and the code for On Order from Pharmacy (OO) was chosen as the reason the medication was not given.
On 03/12/2025 at 12:27 PM, Staff C, Resident Care Manager, acknowledged that Breo Ellipta had not been administered on 3/10/2025, 03/11/2025 and 03/12/2025, and could not provide documentation the pharmacy had been contacted, or the provider had been notified regarding the unavailable medication.
Reference WAC 388-97-1060 (3)(k)(ii) .
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
bedside.
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
Review of the EHR showed Resident 13 had a stage 2 pressure ulcer on the sacrum (bones at the
skin assessment was done on [DATE], documenting Resident 13 had a stage 2 pressure ulcer on the coccyx (tailbone).
Following that assessment in September, October, November, and [DATE], there were only weekly assessments, saying yes or no to new skin impairment, but no skin assessments to show if the facility was monitoring the documented pressure ulcer.
Review of the Quarterly MDSs from [DATE] and [DATE], showed Resident 13 had no pressure ulcers.
During an interview on [DATE] at 12:45 PM, Staff AA, MDS Nurse, regarding the [DATE] skin assessment, said there was no stage for the description in the assessment.
When asked if the [DATE] MDS used the same skin assessment from [DATE], Staff AA said there was a skin assessment on [DATE] and none until [DATE], and to them this meant there were no skin issues at that time.
During an interview on [DATE] at 3:00 PM, Staff B, DNS, said the [DATE] skin assessment was completed by a licensed practical nurse (LPN) and not an RN, and the staff should not have staged it as a stage 2 pressure ulcer.
Staff B said the staging was due to a lack of knowledge and only an RN could stage the pressure ulcer.
Staff B said that Staff AA was a LPN and should have clarified the [DATE] assessment with an RN to confirm it was not a level 2 pressure ulcer.
Reference WAC 388-97-1720 (1)(a)(i-iv)(b) .
During an interview on 03/19/2025 at 10:24 AM, Staff A, Administrator, said their expectation regarding binding arbitrations was for residents or their representatives to be fully aware of what they are signing, that they knew it was optional and not required, and they would know they had 30 days to rescind the agreement.
No associated WAC .
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
During an interview on 03/17/2025 at 4:32 PM, Staff B, Director of Nursing Sservices, said their expectation for an EBP room, was that staff for direct care would gown and glove if touching a resident or linen.
Staff B said it did not meet expectations staff did not wear gowns for wound or catheter care for Resident 13.
When asked if it met expectations that hand hygiene was not done with every glove change, Staff B said no.
Regarding the heel having the wrapping taken off and the heel put into the padded heel protector, said this did not meet expectations and that the wound should have been covered or had a barrier to keep it clean.
Regarding the wound cleanser, Staff B said the wound cleanser should have been left in the resident's room.
Regarding urinary catheter care, Staff B said hand hygiene and new gloves should have happened. <Resident 14> On 03/10/2025 at 12:13 PM, Staff U delivered a lunch tray to Resident 4's room. Resident 4 had a sign outside their door that notified staff they were on contact precautions.
Staff U was not wearing PPE, a gown or gloves, when she entered the room.
Staff U touched Resident 4's water pitcher and cut up their food.
Staff D, RCM/LPN walked by Resident 4's room and saw Staff U in Resident 4's room without PPE on.
Staff D said to Staff U you did not gown up.
Staff D told Staff U to wash her hands using soap and water.
Staff U immediately washed her hands using soap and water and put on PPE, a gown and gloves. <Resident 12> Resident 12 admitted to the facility on [DATE].
According to the Quarterly Minimum Data Set, (MDS, an assessment tool), dated 02/19/2025, Resident 12 was cognitively intact.
Review of Resident 12's medication orders showed an order for Novolin N FlexPen, with 2 units to be subcutaneously (fatty tissue layer) injected two times a day.
On 03/11/2025 at 11:56 AM, Staff R, Registered Nurse, was observed performing Resident 12's insulin injection.
Staff R opened an alcohol wipe, wiped resident 12's right upper arm, and injected the insulin.
Staff R did not don (put on) gloves for the insulin injection.
At 2:20 PM, Staff R, when asked about not wearing gloves for Resident 12's insulin injection 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.
On 03/12/2025 at 12:27 PM, Staff C, Resident Care Manager, said the observation of staff not wearing gloves for an insulin injection did not meet his expectations.
On 03/13/2025 at 2:57 PM, Staff B, Director of Nursing Services, said that her expectation is that staff put on gloves for insulin administration.
Reference WAC 388-97-1320 (1)(c), (2)(b) .
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Shelton Health and Rehabilitation 153 Johns Court Shelton, WA 98584
Findings included .
1) Resident 163 was admitted to the facility on [DATE].
The Admission Minimum Data Set (MDS, an assessment tool), dated 03/09/2025, documented the resident was moderately cognitively impaired and needed substantial to maximal assistance with showers, bathing, and personal hygiene.
On 03/10/2025 at 10:25 AM, Resident 163 stated, I have not had a shower yet, I have been nine days, I requested one today.
Resident 163's care plan interventions, initiated on 03/03/2025 documented resident wanted a shower two times a week on Wednesday and Saturday evenings.
A review of the Point of Care (nursing assistant task documentation) response history for 30 days, the task Bathing - Shower, two times weekly on Wednesday and Saturday evenings documented on 03/08/2025 as not applicable and there was no other documentation listed.
On 03/14/2025 at 10:19 AM, Staff C, Resident Care Manager (RCM)/Registered Nurse, said while looking at Resident 163's Electronic Health Record (EHR) that he did not see a shower documented in the system and his expectation was for the staff to follow the resident's admission orders.
At 2:02 PM, Staff B, Director of Nursing Services (DNS), said she could not find documentation of Resident 163 receiving a shower and her expectation was for the staff to provide resident showers unless they refused.
37044
2) Resident 51 admitted to the facility on [DATE].
Review of the Admission MDS, dated [DATE], showed the resident was cognitively intact and required substantial to maximal assistance with bathing/showering.
On 03/10/2025 at 3:19 PM, Resident 51 reported they were supposed to be bathed every Monday and Thursday, but staff don't show up.
Review of Resident 51's bathing flowsheet showed the resident was scheduled to be bathed every Thursday and Sunday on evening shift.
Review of the bathing record showed for the 30-day period from 02/13/2025 - 03/13/2025, showed the resident was offered/provided bathing 02/23/2025, 03/02/2025 and 03/09/2025.
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Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505507 B.
Wing 03/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Shelton Health & Rehab Center 153 Johns Court Shelton, WA 98584
Findings included .
<Resident 53>
Resident 53 was admitted to the facility on [DATE], with diagnoses that included Major Depressive Disorder (MDD, a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily life), Unspecified Psychosis (is a diagnosis used when a person experiences symptoms of psychosis but does not meet the full criteria for a specific psychotic disorder) and Post Traumatic Stress Disorder (PTSD, a mental health condition that's caused by an extremely stressful or terrifying events).
The Quarterly, Minimum Data Set, (MDS, an assessment tool), dated 02/04/2025, documented Resident 53 was cognitively intact.
Resident 53's PASRR Level I, dated 12/05/2024, documented Resident 53 was diagnosed with PTSD. No other diagnoses were included on the PASRR Level I.
On 03/17/2025 at 2:38 PM, Staff D, Resident Care Manager (RCM), with Staff C, RCM, present, said Resident 53's mental health diagnoses included PTSD, Unspecified Psychosis, Insomnia, & MDD.
When asked to review Resident 53's PASRR, Staff D said the Unspecified Psychosis & MDD were missing from the form.
Staff D said that should have been caught.
On 03/18/2025 at 12:53 PM, Staff B, Director of Nursing Services (DNS), with Staff E, Divisional Director/Regional Registered Nurse present, said Resident 53's mental health diagnoses included PTSD, Psychosis, Insomnia & MDD.
After reviewing the PASRR Level I, Staff B, said the PASRR was incorrect and should have been corrected.
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<Resident 49>
Resident 49 admitted to the facility on [DATE].
Review of the Admission MDS, dated [DATE], showed the resident's diagnoses included non-Alzheimer's dementia, psychotic disorder (severe mental illness that causes abnormal thinking and perceptions) and depression, and the resident was treated with antipsychotic and antidepressant medication during the assessment period.
Review of Resident 49's Level I PASRR, dated 02/04/2025, showed the resident had a diagnosis of major depressive disorder, but not a diagnosis of psychotic disorder.
The assessment determined Level II PASRR evaluation for serious mental illness (SMI) was not indicated.
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Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505507 B.
Wing 03/19/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Shelton Health & Rehab Center 153 Johns Court Shelton, WA 98584
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.