South Creek Post Acute: Staff Abandons Smoking Resident - WA
The July incident at South Creek Post Acute exposed how staff abandoned a resident who required constant supervision, then how administrators covered up the abandonment by falsely documenting the fall as "witnessed" in their investigation report.
Resident 1 had been assessed as cognitively impaired and unable to safely smoke independently or reach the smoking area without help. Her care plan specifically required "supervision provided while resident is smoking." But on July 12, the nursing assistant certified left her alone with a lit cigarette.
"The NAC said she needed to use the restroom and left the resident outside," the resident told inspectors in September. "My lit cigarette fell, and when I leaned forward from my wheelchair to pick it up, I fell from the chair and hit face first."
The resident's glasses were knocked off when she struck the concrete.
The nursing assistant returned two minutes later to find the resident on the ground. But the facility's fall investigation, completed the same day, documented a completely different version of events. According to that report, the nursing assistant "witnessed resident slide out of wheelchair, and fall hitting her head on the concrete."
That was a lie.
Staff C, the residential care manager who conducted the investigation, admitted to inspectors she knew the truth. "Resident 1 had told her the NAC had left at the time of the fall," according to the inspection report. When asked why she documented it as a witnessed fall, Staff C said "she was mistaken" and "must have been thinking about another fall at the time the report was made."
The resident herself had told investigators immediately after the incident: "I fell down. I only hurt my pride."
A family member confirmed to inspectors that the resident "had been left by a staff member when the fall occurred."
The deception went all the way to the top. Staff B, the director of nursing, told inspectors the facility investigation "concluded the resident fall was witnessed based on the statements obtained from Resident 1 and the staff on shift."
But there were no such statements. The resident had told staff she was abandoned. The nursing assistant never claimed to witness the fall.
When inspectors confronted the director of nursing with the contradictions between the facility's investigation and what actually happened, she acknowledged "the witness statement in the facility fall investigation could have been more detailed."
The residential care manager said she "educated the NAC on the smoking times and to not leave residents alone when assisting with smoking" after the incident. But the false documentation remained in the resident's file.
The resident had been admitted earlier that year and was assessed as cognitively intact in June. But by July, her smoking assessment documented cognitive impairment and inability to smoke safely alone. The facility knew she needed constant supervision.
Smoking policies exist specifically because cognitively impaired residents can injure themselves with lit cigarettes, as this case demonstrated. When the resident leaned forward to retrieve her dropped cigarette, she lost her balance and fell from the wheelchair.
The concrete surface caused additional injury when she hit head-first, knocking off her glasses. The impact could have been far worse.
Instead of using the incident to improve safety protocols, administrators chose to falsify records. The residential care manager fabricated a witness account that never existed. The director of nursing accepted that fabrication without question.
The false documentation served the facility's interests by suggesting staff had followed proper procedures. A "witnessed" fall implies the nursing assistant was present and providing required supervision. An "unwitnessed" fall would have revealed the policy violation and abandonment.
But the resident knew what really happened. So did the nursing assistant who left her alone. So did the residential care manager who conducted the investigation.
Federal inspectors found the facility "failed to thoroughly investigate a fall" and placed "residents at risk of unmet care needs and a diminished quality of life." The violation carried minimal harm but revealed systemic problems with both supervision and documentation integrity.
The resident survived her fall with what she described as hurt pride. Her glasses were recovered. But the breach of trust runs deeper than the concrete injury.
She had been promised supervision during a vulnerable activity. Instead, she was abandoned with a lit cigarette, left to fall face-first onto concrete while staff attended to other needs. Then administrators lied about it in official records, protecting staff at her expense.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Creek Post Acute from 2025-09-09 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
SOUTH CREEK POST ACUTE in CENTRALIA, WA was cited for violations during a health inspection on September 9, 2025.
Resident 1 had been assessed as cognitively impaired and unable to safely smoke independently or reach the smoking area without help.
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.