Woodard Creek Health & Rehab: AMA Discharge Failures - WA
That finding sits at the center of a September 4 complaint inspection at the 150-bed facility, which also found that two residents discharged against medical advice left without required paperwork, without confirmed medication transfers, and without documentation that anyone had tried to make their departures safe.
The resident who didn't return was identified in the inspection report only as Resident 5. The report doesn't describe the resident's medical condition or explain what eventually happened. What it does describe is a staff member, identified as Staff A, who told inspectors that afternoon that he wasn't sure the situation should have been treated as an elopement — because the resident had signed out of the facility.
Staff A acknowledged the resident had not come back as expected. He acknowledged staff did not know where the resident was during that period. He still wasn't certain the elopement protocol applied.
It did. Elopement protocols exist precisely for situations where a resident leaves and cannot be accounted for. Signing out does not resolve the question of whether someone is safe.
The other two cases involved residents who left against medical advice, a situation the facility's own policy addresses in detail. The policy, dated October 2021, requires staff to educate residents on the risks of leaving without a physician's approval, notify the attending physician, document that conversation, arrange for medications to be sent to a pharmacy, and have the resident sign a Release of Responsibility form. If the resident refuses to sign, two staff members are supposed to witness that refusal and document it.
None of that happened as required for Resident 3 or Resident 6.
Resident 3 had been admitted with congestive heart failure and cirrhosis. Both are serious, chronic conditions that require ongoing medication management. Progress notes from June 8 recorded that the resident left the building against medical advice and wouldn't wait for medications stored at the facility, but planned to return for belongings.
When inspectors spoke with Resident 3 on July 28, the resident said the facility never sent medications to a pharmacy after the departure. The resident also said something that complicates the straightforward picture of a voluntary discharge: they felt they had been forced out and did not want to leave.
Staff B, who reviewed the record with inspectors on September 4, confirmed the documentation fell short across the board. She said she had tried to get Resident 3 to stay but hadn't written a note about it. She said medications should have been faxed to a pharmacy but couldn't tell from the record whether that happened. She said the Release of Responsibility form should have been completed but wasn't in the file. "The record should explain everything that was done to make the discharge as safe as possible," she told inspectors. It didn't.
Resident 6 had chronic obstructive pulmonary disease and was oxygen-dependent, meaning the resident required supplemental oxygen to breathe adequately. A progress note from July 29 recorded that the resident requested to leave against medical advice and that the administrator and family had been notified. The note said staff followed facility protocol for such discharges.
Staff B told inspectors the Release of Responsibility form was missing from that record too, and that documentation of steps taken to ensure a safe discharge was absent.
Oxygen-dependent residents who leave a facility without confirmed access to supplemental oxygen face immediate risk. The inspection report does not say whether Resident 6 had oxygen arranged, or what happened after the departure.
The inspection was classified as a complaint investigation. The level of harm was cited as minimal harm or potential for actual harm. That classification reflects what inspectors could verify from the record, not necessarily what residents experienced after they left. For Resident 3, who said they were forced out against their will and left without medications for a failing heart and a damaged liver, the gap between those two things may be wider than any inspection report can measure.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodard Creek Health & Rehabilitation from 2025-09-04 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Woodard Creek Health & Rehabilitation in OLYMPIA, WA was cited for violations during a health inspection on September 4, 2025.
The resident who didn't return was identified in the inspection report only as Resident 5.
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.