Woodard Creek: Resident Disappearances Unreported - WA
Woodard Creek Health & Rehabilitation failed to report two resident departures to Adult Protective Services, even though facility staff later acknowledged both cases should have triggered mandatory notifications, according to a September federal inspection.
The first incident involved Resident 5, who had cognitive impairment and required staff assistance with daily activities. Progress notes from June 6, 2025, documented the resident wasn't in their room at shift change and their lunch remained untouched.
Staff couldn't locate the resident the following day either. They called family members, with one responding they hadn't seen the resident. The last confirmed sighting was during morning medication distribution on June 6.
Later documentation revealed what happened. Resident 5 had signed out, telling staff they were going to get a wheelchair for an upcoming discharge. The resident never returned.
Family initially didn't know the resident's whereabouts but eventually located them. The facility classified the departure as an "against medical advice" discharge since the resident failed to return as expected.
Staff B, who was off duty during the incident, told inspectors on September 4 she would have reported this as an elopement to the state agency. "This discharge should have been called to APS," she said.
Staff A wasn't certain the departure qualified as an elopement because the resident had signed out. But he acknowledged the facility didn't know where the resident was when they failed to return. "This discharge should have been called to APS," he agreed.
The second case involved Resident 6, admitted with chronic obstructive pulmonary disease and oxygen dependence. No assessment was completed for this resident.
Progress notes from July 29, 2025, documented Resident 6 requesting to leave against medical advice. Staff notified the administrator and family, following what they described as facility protocol for such discharges.
Both Staff A and Staff B told inspectors this departure also should have been reported to Adult Protective Services.
The facility's failure to make required notifications violated Washington state regulations requiring reports when residents leave unexpectedly or against medical advice. The violations affected multiple residents and created potential for actual harm, according to the inspection findings.
Neither staff member interviewed could explain why the mandatory reports weren't filed, despite both acknowledging the legal requirement. The discrepancy between what staff knew they should do and what actually happened highlights gaps in the facility's protective protocols.
For Resident 5's family, the confusion meant hours of not knowing where their cognitively impaired relative had gone. The resident had signed out for what seemed like a routine errand but disappeared into an afternoon that stretched into the next day.
The inspection documented how quickly situations can deteriorate when facilities fail to follow mandatory reporting requirements. A resident walks out for a wheelchair and vanishes. Another requests discharge and leaves. In both cases, the state agency that could have provided immediate assistance never received notification.
Staff members recognized the failures during interviews, repeatedly telling inspectors the departures should have triggered calls to Adult Protective Services. Their acknowledgment underscored that this wasn't a matter of unclear regulations or ambiguous circumstances.
The facility knew what to do. They simply didn't do it.
Washington regulations require nursing homes to notify Adult Protective Services when residents leave unexpectedly or against medical advice, recognizing that vulnerable adults face heightened risks when they depart care facilities without proper planning or support systems in place.
For Resident 5, who required assistance with daily activities due to cognitive impairment, the failure to report meant no immediate safety net when family couldn't initially locate them. The resident's stated purpose for leaving - getting a wheelchair for discharge - suggested confusion about the discharge process itself.
Resident 6's case involved someone dependent on oxygen who requested to leave against medical advice. The medical complexity made notification even more critical, yet the required call never happened.
The inspection found the facility's own staff understood the reporting requirements but failed to implement them consistently. Both departures occurred months before the September inspection, suggesting the notification failures weren't isolated incidents but part of a pattern of inadequate protective protocols.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WOODARD CREEK HEALTH & REHABILITATION in OLYMPIA, WA was cited for violations during a health inspection on September 4, 2025.
The first incident involved Resident 5, who had cognitive impairment and required staff assistance with daily activities.
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.