Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Hill Rehabilitation And Care Center during CMS and state inspections, most recent first.
Three residents who required assistance with ADLs did not receive regular bathing as scheduled, with documentation and interviews confirming missed showers due to bath aides being reassigned to other duties and reduced staffing. Staff acknowledged that all residents were scheduled for twice-weekly bathing, but scheduling and staffing issues led to inconsistent bathing for multiple residents.
A registered nurse removed a resident's PICC line after discovering it was leaking and could not be flushed, but did so without notifying the physician or obtaining a provider order, contrary to facility policy. The DON confirmed that physician notification and an order were required prior to PICC line removal.
The facility did not create adequate baseline care plans within the required timeframe for four newly admitted residents, resulting in missing documentation and interventions for conditions such as stroke, heart failure, dialysis, and IBS. Staff interviews confirmed that key care needs and treatment details were not included in the care plans or Kardex, despite being necessary for continuity of care.
Staff were observed repeatedly failing to perform hand hygiene and change gloves between resident contacts and after touching potentially contaminated surfaces during meal service. Multiple staff touched residents, wheelchairs, tables, and then handled food, drinks, and utensils without appropriate glove changes or handwashing, increasing the risk of cross-contamination.
The facility did not consistently post Enhanced Barrier Precautions (EBP) signage for residents with indwelling devices or receiving IV antibiotics, resulting in staff not being properly informed of required PPE during high-contact care. Additionally, a nursing technician failed to perform hand hygiene after administering medications and topical ointment, contrary to facility expectations. These lapses were acknowledged by staff and management during interviews.
The facility did not obtain informed consent prior to administering a psychotropic medication to a resident with depression, and accepted vaccine consents from another resident with severe cognitive impairment who was not able to make informed decisions. Additionally, a psychotropic medication consent was completed under the wrong medication category, resulting in inaccurate information being provided to the resident's representative.
The facility did not follow its grievance process to address concerns raised by two residents during Resident Council meetings, including issues with slow-draining showers, uncollected towels, and untimely bed linen changes. Staff confirmed that grievance forms were not completed and concerns were not followed up on as required by policy.
Controlled medication ledger reviews showed numerous missing signatures for end-of-shift narcotics counts on multiple medication carts. Nursing staff and the DON confirmed the missing signatures and acknowledged inconsistent accounting practices, which did not follow accepted standards for controlled substance documentation.
A resident with a history of CHF and kidney disease was admitted after hospitalization with a fluid restriction order, but the facility failed to include this order in provider instructions. Although the care plan and Kardex referenced the restriction, there was no clear guidance for staff on fluid amounts per shift or meal, and the kitchen was not informed. Staff interviews revealed inconsistent practices and lack of documentation for total fluid intake, resulting in the resident's fluid intake not being accurately monitored or reconciled.
A resident dependent on tube feeding did not consistently receive nutrition according to provider orders, with staff failing to document the total amount of enteral nutrition administered per shift and, on several occasions, administering more than the prescribed amount. The registered dietitian acknowledged inconsistencies and miscommunication regarding documentation in the MAR.
Surveyors found an unlocked and unattended medication cart, expired Hibiclens in a medication cart, and an open, undated bottle of Tubersol in the medication refrigerator. Staff acknowledged that the cart should have been locked, expired medications should have been discarded, and opened injectables should have been dated, indicating lapses in medication security and management.
A resident with multiple diagnoses, including malnutrition and respiratory failure, was referred to and began receiving hospice services. The facility's hospice agreement did not specify a designated staff member to coordinate care and communication with the hospice provider, and staff confirmed that no hospice liaison had been appointed.
A resident with a history of respiratory failure and comfort-focused care orders experienced a significant increase in oxygen requirements, receiving 8 LPM via mask instead of the ordered 2-4 LPM via nasal cannula. There was no documentation that the medical provider was notified of this change in condition, and staff interviews confirmed the lack of provider notification prior to the resident being found unresponsive and subsequently pronounced deceased.
The facility failed to investigate and follow up on a resident's grievance regarding missing property and money. Despite reporting the issue to multiple staff members, the grievance was not documented or resolved, leading to an unresolved complaint and potential diminished quality of life for the resident.
A resident reported missing property and money to multiple staff members, but the facility failed to document or report the complaint to the State Agency as required. Staff acknowledged the complaint but did not follow proper procedures, leading to a deficiency in reporting potential misappropriation.
A facility failed to update a resident's care plan to reflect the need for female-only personal care after the resident experienced trauma triggered by a male nurse. Despite assurances, the resident continued to receive care from male staff, and the care plan and Kardex did not include the necessary intervention.
A facility failed to investigate the causes of falls and assess the need for additional interventions for a cognitively impaired resident with a history of falls. Despite a care plan, the resident experienced multiple falls, and no new interventions were implemented. The DON was unaware of one fall, and staff noted the resident's frequent attempts to self-transfer.
Failure to Provide Regular Bathing for Dependent Residents
Penalty
Summary
The facility failed to provide regular bathing for three of six sampled residents who required assistance with activities of daily living (ADLs), specifically bathing. Resident 2, who was cognitively intact and required extensive assistance due to morbid obesity, diabetes, and a chronic pressure ulcer, was scheduled for bathing twice weekly but experienced missed showers over several months. Documentation showed significant gaps between bathing dates, including a 10-day span without bathing, and the resident reported that bath aides were reassigned to other duties, resulting in missed showers. Resident 3, also cognitively intact and requiring supervision for ADLs, was scheduled for twice-weekly bathing but received only three baths in October and three in September, with periods where no bathing or offers of bathing were documented. Resident 4, who required maximum assistance for bathing due to chronic conditions, reported a reduction in bathing frequency and records confirmed inconsistent bathing schedules. Staff interviews confirmed that bath aides were frequently reassigned to other duties, and there was a period when bathing was missed due to decreased bath aide hours and scheduling issues. The Director of Nursing and Nurse Manager acknowledged that all residents were scheduled for twice-weekly bathing, but staffing adjustments and a low census led to missed showers for multiple residents. These findings were based on interviews, record reviews, and care plan documentation, and reference was made to WAC-388-97-1060(2)(b) regarding the requirement to provide care and assistance for ADLs.
PICC Line Removed Without Physician Notification or Order
Penalty
Summary
A registered nurse (RN) failed to follow accepted standards of clinical practice regarding the care and removal of a peripherally inserted central catheter (PICC) line for a resident. The resident, who was cognitively intact and required maximum assistance with activities of daily living, had a history of pyogenic arthritis and chronic pain. During an assessment, the RN discovered the resident's PICC line was leaking and was unable to flush it with a syringe. Without notifying the physician or obtaining a provider order, the RN removed the PICC line from the resident's arm. Documentation review and staff interviews confirmed that the facility's policy required physician notification and a provider order prior to the removal of a PICC line. The RN admitted to not being aware of this requirement at the time of the incident. The Director of Nursing also confirmed that the facility policy was not followed in this instance, as there was no documentation of provider notification or an order before the PICC line was removed.
Failure to Develop Timely and Comprehensive Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop adequate baseline care plans within the required timeframe for four recently admitted residents, resulting in a lack of continuity of care. For one resident with a recent stroke, diabetes, chronic kidney disease, and heart failure, there was no documentation in the care plan or Kardex regarding the use of a right wrist brace, its purpose, who was responsible for its application, or how long it should be worn. Additionally, the care plan did not address the resident's primary physical problems and functional limitations associated with heart failure, nor did it include the resident's goals or interventions to achieve those goals. Another resident admitted with chronic kidney disease, heart failure, ventricular fibrillation, and a defibrillator had no care plan addressing the treatment for DVT prevention, the presence of a defibrillator, or the associated physical problems and interventions. Similarly, a resident with end-stage renal disease requiring dialysis had a care plan that failed to document the dialysis schedule, the dialysis center's contact information, or specific interventions related to dialysis, despite relevant orders being present in the medical record. A fourth resident with a hip fracture and irritable bowel syndrome (IBS) with constipation had no care plan focus on their IBS diagnosis, bowel monitoring, or related interventions, even though the resident experienced ongoing bowel issues and received medications for both constipation and diarrhea. Staff interviews confirmed that these care plan omissions were not in line with facility expectations and should have been addressed.
Failure to Perform Hand Hygiene and Change Gloves During Meal Service
Penalty
Summary
Staff in both the first and second floor dining rooms failed to perform proper hand hygiene and change gloves as required during meal service. On multiple occasions, a speech therapist and nursing assistants were observed touching residents, wheelchairs, tables, and personal items, then handling food, drinks, and utensils without changing gloves or performing hand hygiene in between tasks. For example, a staff member was seen touching residents and their wheelchairs, then serving food and condiments, opening drink containers, and adjusting napkins, all while wearing the same gloves. Another staff member touched a resident's arm, a sink faucet, and a refrigerator, then handled a cup by the rim and gave it to a resident without washing hands. Similar lapses were observed with other staff, who handled drinks, straws, and cups by the areas that would come into contact with residents' mouths, again without appropriate glove changes or hand hygiene. These actions were confirmed through staff interviews, where staff acknowledged the need for hand hygiene and glove changes between resident contacts and after touching potentially contaminated surfaces. The failure to follow proper infection control protocols was observed in both dining rooms and involved multiple staff members during meal service, placing residents at risk for foodborne illnesses. The observations were corroborated by the facility's infection preventionist, who stated that gloves should be removed and hands washed when moving between residents and personal surfaces.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to implement and maintain proper infection prevention and control measures, specifically regarding the use of Enhanced Barrier Precautions (EBP) for residents at increased risk of multidrug-resistant organism (MDRO) transmission. Multiple residents, including those with indwelling urinary catheters, feeding tubes, IV lines, and those receiving intravenous antibiotics, did not have EBP signage posted at or near their rooms to inform staff of the required personal protective equipment (PPE) during high-contact care activities. Observations confirmed the absence of EBP signage for several days after admission for these residents, despite facility policy and staff statements indicating that such signage should be in place for residents with these risk factors. Staff interviews revealed that the process for posting EBP signage was disrupted due to the absence of the Admissions Nurse, resulting in a breakdown of the admission process and failure to ensure signage was consistently placed. Staff members, including a nurse manager and infection preventionist, acknowledged the lack of signage and confirmed that it should have been present for the affected residents. The absence of EBP signage meant that staff were not consistently reminded to use gowns and gloves during high-contact care, as required for residents with wounds, indwelling devices, or those receiving certain treatments. Additionally, the facility failed to ensure proper hand hygiene practices during medication administration. An observation of a nursing technician administering medications and topical ointment to a resident showed that the staff member did not use hand sanitizer after removing gloves or upon entering and leaving the resident's room. The staff member acknowledged forgetting to perform hand hygiene, and the director of nursing confirmed that the expectation was for staff to perform hand hygiene after glove removal and between residents.
Failure to Obtain Accurate Informed Consent for Medications and Vaccines
Penalty
Summary
The facility failed to ensure that informed consents explaining the potential risks and benefits associated with psychotropic medications and vaccines were accurately completed and obtained from residents or their representatives prior to administration. For one resident with depression, psychotropic medication (Duloxetine) was administered daily for 12 days before the resident signed the informed consent form. The nurse manager confirmed that the consent was not obtained prior to the first dose, as required, and no earlier consent was found in the records. For another resident with dementia and bipolar disorder, who had severely impaired cognitive skills and required assistance with all decision making, staff obtained and accepted vaccine consents signed by the resident, despite documentation that the resident was not capable of making informed decisions. Additionally, the informed consent for a psychotropic medication (Depakote) was completed under the wrong medication category, providing inaccurate information to the resident's representative. The nurse manager acknowledged these errors, confirming that the consents should have been obtained from the resident's next of kin and that the medication category was incorrectly documented.
Failure to Address Resident Council Grievances Through Facility Process
Penalty
Summary
The facility failed to utilize its grievance process to address and follow up on concerns raised by residents during Resident Council meetings. Specifically, two residents reported issues such as slow-draining showers, towels not being picked up after bathing, and bed linens not being changed in a timely manner. These concerns were documented in Resident Council meeting minutes over several months, but there was no evidence that the facility's Grievance Official evaluated, investigated, or took action to resolve these issues as required by the facility's grievance policy. The policy mandates that the Grievance Official respond within three working days, complete grievance resolution forms, and follow up with the individual who expressed the concern, but no such documentation or follow-up was found in the grievance log or binder for the period reviewed. Interviews with staff confirmed that the grievance process was not consistently used for concerns raised during Resident Council meetings, and that grievance forms were not completed for these issues. The Activity Director and the former Grievance Official both acknowledged that the process was not followed and that concerns were not addressed or followed up on in a timely manner. This lack of action was confirmed by the absence of documentation in both the Resident Council minutes and the facility's grievance records.
Failure to Properly Account for Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications were properly accounted for in accordance with accepted professional standards. Review of controlled substance ledger books for three medication carts revealed numerous missing signatures on required end-of-shift narcotics counts. Specifically, for Medication Cart 1 on the first floor, 37 out of 75 signature lines were left blank over a period of several weeks. For Medication Cart 1 on the second floor, 93 out of 189 signature lines were missing, and for Medication Cart 2 on the second floor, 93 out of 189 signature lines were also missing. These omissions were confirmed by interviews with nursing staff responsible for the medication carts, who acknowledged the missing signatures and confirmed that the facility's process was to follow the standard practice of dual nurse verification and sign-off. Further, the Director of Nursing acknowledged the inconsistent accounting of controlled substances during an interview. The findings were based on both record review and staff interviews, and the facility's process was compared to established standards as described in a referenced professional article. No information was provided regarding specific residents affected, their medical histories, or their conditions at the time of the deficiency.
Failure to Accurately Monitor and Document Fluid Intake for Resident on Fluid Restriction
Penalty
Summary
The facility failed to ensure accurate documentation and monitoring of a resident's fluid intake while the resident was on a fluid restriction. The resident, who had a history of congestive heart failure and kidney disease, was admitted following hospitalization for heart failure and septic shock, with hospital records indicating a fluid restriction order of 2000 mL per day. However, the facility's provider orders did not include this fluid restriction, although the care plan and Kardex referenced it. There was no clear guidance on how much fluid was to be provided per shift or how much was to be given with meal trays and between meals. Observations showed that the resident had access to a water pitcher and received oral nutrition supplements, but there was no consistent or accurate documentation of total fluid intake. Staff interviews revealed confusion regarding the process for monitoring and documenting fluid intake, with some staff estimating amounts consumed and others unsure of the specific orders or responsibilities. The kitchen staff was not provided with instructions regarding the fluid restriction, and the resident's medical record lacked documentation of shift-by-shift fluid intake reconciliation. The lack of clear provider orders, absence of specific instructions for staff, and failure to document and monitor fluid intake placed the resident at risk. The deficiency was identified through observation, interview, and record review, which confirmed that the facility did not maintain an accurate account of the resident's fluid intake as required for residents on fluid restrictions.
Failure to Administer and Document Tube Feeding per Provider Orders
Penalty
Summary
The facility failed to ensure that a resident who was dependent on tube feeding received nutrition according to provider orders. The resident, admitted with a progressive neurological condition and severe malnutrition, was assessed as cognitively intact and required enteral nutrition. Observations confirmed the presence of tube feeding equipment in use. However, review of the Medication Administration Records (MAR) for both May and June revealed inconsistent and incomplete documentation of the actual amounts of nutrition administered per shift. Nurses often recorded only the hourly rate or a single value, rather than the total amount delivered per shift as ordered. Further review showed that on several occasions, the amount of enteral nutrition administered exceeded the physician's prescribed rate, with overages documented on multiple shifts. The registered dietitian acknowledged that the medical record did not consistently show that the prescribed rate was provided and noted miscommunication regarding MAR documentation requirements. These findings were based on observation, interview, and record review, and were shared with facility staff during the survey.
Medication Security and Expired Medication Management Deficiencies
Penalty
Summary
Surveyors observed multiple deficiencies related to medication management within the facility. On the second floor, an unlocked and unattended medication cart was found at the beginning of Unit B - Transitional Care Unit. The cart remained unsecured for an extended period while the responsible LPN was away from the area. The LPN acknowledged that the cart should have been locked when unattended. Additionally, on the first floor, an expired eight-ounce bottle of Hibiclens was found in a medication cart during an inspection. The LPN present confirmed the medication was expired and should have been discarded, noting that all medication cart nurses are responsible for checking and disposing of expired items. Further inspection of the second floor medication room revealed an open, undated bottle of Tubersol solution in the medication refrigerator. The Nurse Manager confirmed that Tubersol is only valid for 30 days after opening and, without a date, should have been discarded. The DON also stated that undated Tubersol should be thrown away if the date of opening is unknown. These findings demonstrate failures in securing medication carts, timely disposal of expired medications, and proper dating of opened injectable medications.
Lack of Designated Hospice Liaison for Resident Receiving Hospice Services
Penalty
Summary
The facility failed to identify a designated interdisciplinary team member to act as a liaison for coordinating care and communication with the hospice provider for a resident receiving hospice services. The resident, who was able to make decisions regarding their care and had diagnoses including malnutrition, asthma, and respiratory failure, was referred for hospice services and began receiving them. Review of the facility's hospice agreement showed that while it outlined the services and responsibilities of both the facility and the hospice provider, it did not specify who within the facility was responsible for collaborating with hospice. Staff interviews confirmed that although arrangements for hospice were made by social services, no specific hospice liaison had been appointed.
Failure to Notify Provider of Resident's Increased Oxygen Needs
Penalty
Summary
The facility failed to ensure timely notification to a medical provider regarding a resident's change in condition. The resident, who had recently been discharged from the hospital following respiratory failure and was on comfort-focused treatment per their POLST, was ordered to receive oxygen at 2-4 LPM via nasal cannula. On the day in question, the resident was observed to require oxygen via mask at 8 LPM, a significant increase from the prescribed amount. There was no documentation that the medical provider was notified of this increased oxygen need after their earlier visit that day. Staff interviews confirmed that there was an expectation for staff to notify the medical provider of any changes in a resident's respiratory status, including increased oxygen requirements. However, both the Resident Care Manager and the DON were unable to find any evidence that the provider had been informed of the resident's condition change. The nurse on duty believed the provider had already been notified, but this was not substantiated in the records. The resident was later found unresponsive and was pronounced deceased shortly thereafter.
Failure to Investigate and Follow-Up on Resident Grievance
Penalty
Summary
The facility failed to investigate and provide timely follow-up on a grievance reported by Resident 2 regarding missing property and money. During their admission, Resident 2 reported the missing items to multiple nursing assistants and a charge nurse, who informed them that the administration was aware and investigating. However, a review of the grievance and incident logs showed no entries for Resident 2's complaint. Staff C, the charge nurse, confirmed the resident's report but could not recall the investigation details or outcome. Staff D from Social Services mentioned that the resident's concern was noted on a scrap of paper, and while the missing book was found, the money was not, and no proper documentation or follow-up was conducted. The administrator confirmed that the grievance was not documented or resolved appropriately, leading to an unresolved grievance for Resident 2. The facility's policy on safeguarding residents' belongings, revised in December 2023, mandates prompt response and investigation of complaints, with notification of results within 10 working days. Despite this policy, the facility did not document or follow up on Resident 2's grievance, resulting in a failure to address the resident's concerns adequately. This oversight placed Resident 2 at risk of having unresolved grievances and a diminished quality of life, as their complaint about missing property and money was not properly investigated or resolved.
Failure to Report Allegation of Misappropriation
Penalty
Summary
The facility failed to ensure an allegation of potential misappropriation was reported to the State Agency as required. Resident 2 reported missing property and money to multiple nursing assistants and a charge nurse during their admission. The charge nurse informed the resident that the facility administration was aware and investigating the concern. However, a review of the incident logs from January to April 2024 showed no entries for Resident 2's complaint. Staff interviews confirmed that the complaint was known to the facility staff but was not properly documented or reported. Staff C, the charge nurse, acknowledged being informed of the missing items but did not follow up on the investigation. Staff D from Social Services confirmed that the resident's book was found, but the money was still missing. Despite this, the complaint was not escalated or reported as required. The facility administrator confirmed that the complaint was not reported to the State Agency, as mandated by regulations.
Failure to Implement Care Plan for Female-Only Personal Care
Penalty
Summary
The facility failed to care plan and implement an identified intervention for a resident who had trauma triggered by care provided by a male nurse. Despite an investigation indicating that the resident's care plan was updated to include female-only care for personal care, the care plan and Kardex did not reflect this intervention. Interviews with the resident's representative and staff confirmed that the resident continued to receive personal care from male staff, contrary to the supposed care plan update. The deficiency was confirmed by the facility's Social Services and Administrator, who acknowledged that the intervention should have been added to the care plan.
Failure to Investigate Falls and Implement Effective Interventions
Penalty
Summary
The facility failed to thoroughly investigate the causes of falls and assess the need for additional effective interventions for a resident who was severely cognitively impaired and had a history of falls. The resident required moderate staff assistance for transfers, toileting, and walking, and supervision in their wheelchair. Despite having a care plan in place that included offering toileting assistance every two hours and ensuring the resident's environment was safe, the resident experienced multiple falls in March 2024. The incident logs and progress notes did not contain sufficient details regarding the falls, and no new interventions were implemented to prevent further falls. On one occasion, the resident was found lying face down on the floor after attempting to self-transfer, and on another, the resident was found on the floor with no indication of whether the call light was used. The Director of Nursing was unaware of one of the falls and acknowledged that the fall reports lacked completeness and additional interventions. Staff interviews revealed that the resident attempted to go to the bathroom more frequently than the care plan's two-hour assistance schedule, indicating a need for reassessment of the resident's needs and fall prevention strategies.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Spokane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spokane Veterans Home | 0.3 mi | ★★★★★ | 1 | 0 |
| Touchmark On South Hill Nursing | 2 mi | — | 0 | 0 |
| Alderwood Manor | 2.3 mi | ★★★★★ | 24 | 0 |
| Rockwood South Hill | 2.5 mi | ★★★★★ | 1 | 0 |
| North Central Care Center | 3.6 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.