Woodard Creek Health & Rehab: Dialysis Records Gap - WA
The findings at Woodard Creek Health & Rehabilitation came from a complaint inspection completed May 29, 2026.
The dialysis patient, identified in inspection records as Resident 2, had been attending sessions three times a week since admission, on Tuesdays, Thursdays, and Saturdays. That schedule shifted to Mondays, Wednesdays, and Fridays on May 4, 2026. Through all of it, the documentation trail went nearly silent.
The last completed pre- and post-dialysis evaluation in the resident's electronic health record was dated April 30. The next one didn't appear until May 20, a gap of three weeks. The paper communication forms that travel between the facility and the dialysis center, carrying information about the patient's condition, medications, and fluid status, also stopped after April 30 and didn't resume until a May 27 appointment.
Inspectors identified six specific dates on which no vital signs were sent to the dialysis center: April 4, April 7, April 21, May 2, May 27, and one form with no date at all. The April 30 form had no information from the dialysis center recorded on it.
When inspectors interviewed Staff K, a licensed practical nurse and unit manager, on May 26, she said she expected a transfer assessment, a full set of vital signs, and a face sheet to accompany a resident to dialysis. When the resident returned, staff were supposed to enter the remaining information. She said a pre- and post-dialysis form should have been in the electronic health record.
Asked whether Resident 2 had even attended dialysis during the three-week gap between April 30 and May 20, Staff K said she could not determine that from the electronic record. She said she would need to search for hard copies. She also acknowledged that the communication forms sent between the facility and the dialysis center could not be located in the resident's file.
The interim administrator, Staff M, was more direct when inspectors spoke with her on May 29. She said the facility lacked the documentation to show that staff knew what had happened to the resident at dialysis, what medications had been given, or whether the resident had increased fluid removal needs. She said the facility had reached out to the dialysis center to try to recover the missing communication forms.
The second violation involved two residents who had both been discharged in mid-April. Resident 127, described in inspection records as cognitively intact, left the facility on April 17. Resident 142, also cognitively intact, was discharged the day before, on April 16. A family member of Resident 127 reported to inspectors that their relative had been sent home with Resident 142's medication.
The interim director of nursing, Staff L, confirmed it during an interview on May 28. She acknowledged that the facility had dispatched a nurse to Resident 127's home after the discharge to retrieve Resident 142's medication. She also acknowledged that sending the medication home with the wrong resident was a violation of Resident 142's personal health information.
The inspection classified the dialysis documentation failures as causing minimal harm or the potential for actual harm, affecting few residents. What the record cannot show, because the records don't exist, is what Resident 2's condition was during those weeks of missed documentation, what the dialysis center observed, or whether anything that happened during treatment was ever communicated back to the nurses responsible for the patient's care.
The family member who reported the medication mix-up was the one who flagged it. Without that call, there is no indication in the inspection report that the facility would have known the wrong medication had left the building.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodard Creek Health & Rehabilitation from 2026-05-29 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 20, 2026 · Our methodology
Woodard Creek Health & Rehabilitation in OLYMPIA, WA was cited for violations during a health inspection on May 29, 2026.
The findings at Woodard Creek Health & Rehabilitation came from a complaint inspection completed May 29, 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.