South Creek Post Acute: Elopement Plan Failure - WA
The resident, identified only as Resident 2 in inspection records, was admitted to the facility and assessed for elopement risk on March 13, 2026. The assessment came back high risk. Two days later, a physician's note confirmed the same conclusion. An elopement care plan, the document that would have assigned specific interventions to staff, was never created.
Not in March. Not in April. Not until the day after the resident was already gone.
The care plan was initiated on April 21, 2026, according to records reviewed by inspectors. That was one day after the facility's own investigation documented the elopement.
Staff C, the facility's Residential Care Manager and a registered nurse, told inspectors the process was supposed to work in the opposite direction. "Usually an elopement care plan was triggered by a positive elopement risk assessment," she said during an interview on April 30. She acknowledged that after Resident 2's March 13 assessment, it did not look like a care plan had been initiated.
The administrator, identified as Staff A, said she would have expected a care plan to be in place the moment a resident was assessed as high risk.
Nobody explained why it wasn't.
The resident assessed as high risk was documented as cognitively intact on a Medicare assessment dated March 19, 2026. That detail matters. A cognitively intact person assessed as a high elopement risk is someone who has likely expressed intent, made attempts, or demonstrated behavior that staff recognized as dangerous. The risk was not theoretical. It was documented by the clinical team and confirmed in writing by a physician.
For thirty-nine days, that documentation sat in the record with no corresponding plan.
Elopement from a care facility is not a minor incident. Residents who leave unsupervised face exposure, traffic, falls, and medical crises without anyone nearby to intervene. In this case, the resident reached a relative's home, which meant the outcome was not the worst possible one. The facility's own investigation, dated April 20, recorded what happened.
The care plan arrived the next morning.
South Creek Post Acute, located at 917 South Scheuber Road in Centralia, was inspected on April 30, 2026, in response to a complaint. Inspectors reviewed three residents' care plans and found the elopement planning failure in one of them. The deficiency was cited at a level of minimal harm or potential for actual harm, the lower end of the federal harm scale, a designation that reflects the outcome rather than the gap in care that preceded it.
The administrator told inspectors she would have expected a care plan when the risk assessment came back positive. The care manager said the same. Both described a system that should have worked. Neither offered an account of why, in this case, it didn't.
What the record shows is a resident assessed as high risk on March 13, a physician who documented the same concern on March 15, and a facility that took no documented protective action for the next five and a half weeks. The resident left on April 20. The paperwork followed on April 21.
The relative's house was close enough to reach.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Creek Post Acute from 2026-04-30 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 7, 2026 · Our methodology
South Creek Post Acute in CENTRALIA, WA was cited for violations during a health inspection on April 30, 2026.
The resident, identified only as Resident 2 in inspection records, was admitted to the facility and assessed for elopement risk on March 13, 2026.
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.