Spokane, WA

South Hill Rehabilitation And Care Center

3-star overall rating with 3-star inspections with 13 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

17 East 8th Avenue, Spokane, WA

(509) 474-5678

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

113

Certified beds

Average residents

89

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Ensign Group

Operator or chain grouping

Approved since

1992-06-06

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

329 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.72

Registered nurse staffing · state 0.88 · national 0.68

LPN hours / resident day

1.14

Licensed practical nurse staffing · state 0.81 · national 0.87

Aide hours / resident day

2.62

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

4.48

All reported nurse hours · state 4.39 · national 3.89

Licensed hours

1.86

RN + LPN hours · state 1.70 · national 1.54

Weekend hours

3.71

Weekend nurse staffing · state 3.79 · national 3.43

Weekend RN hours

0.43

Weekend registered nurse coverage · state 0.63 · national 0.47

Physical therapist

0.19

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.65

CMS adjusted RN staffing hours

Adjusted total hours

4.05

CMS adjusted total nurse staffing hours

Case-mix index

1.51

Higher values indicate more complex resident acuity

RN turnover

55%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

62%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,686

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

38.96

Composite VBP score used to determine payment impact.

Payment multiplier

0.9920

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.93

Baseline 16.67% · Performance 20.54% · Measure score 1.93 · Achievement 1.93 · Improvement 0

Healthcare-associated infections

5.27

Baseline 5.01% · Performance 6.26% · Measure score 5.27 · Achievement 5.27 · Improvement 0

Total nurse turnover

1.10

Baseline 59.43% · Performance 59.20% · Measure score 1.10 · Achievement 1.10 · Improvement 0

Adjusted total nurse staffing

7.29

Baseline 4.36 hours · Performance 5.15 hours · Measure score 7.29 · Achievement 7.29 · Improvement 5.08

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 8.58%
10.72%
2.1 pts better
No Different than the National Rate · Eligible stays 365 · Observed rate 7.12% · Lower 95% interval 6.35%
Discharge to community 51.44%
50.57%
0.9 pts better
No Different than the National Rate · Eligible stays 390 · Observed rate 46.41% · Lower 95% interval 47.21%
Medicare spending per beneficiary 0.88
1.02
0.1 pts better
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 239 · Denominator 239
Falls with major injury 0.84%
0.77%
0.1 pts worse
Numerator 2 · Denominator 239
Discharge self-care score 37.7%
53.69%
16 pts worse
Numerator 69 · Denominator 183
Discharge mobility score 34.43%
50.94%
16.5 pts worse
Numerator 63 · Denominator 183
Pressure ulcers or injuries, new or worsened 2.09%
2.29%
0.2 pts better
Numerator 5 · Denominator 239 · Adjusted rate 2.25%
Healthcare-associated infections requiring hospitalization 6.26%
7.12%
0.9 pts better
No Different than the National Rate · Eligible stays 222 · Observed rate 5.41% · Lower 95% interval 3.97%
Staff COVID-19 vaccination coverage 9.47%
8.2%
1.3 pts better
Numerator 18 · Denominator 190
Staff flu vaccination coverage 69.42%
42%
27.4 pts better
Numerator 84 · Denominator 121
Discharge function score 43.17%
56.45%
13.3 pts worse
Numerator 79 · Denominator 183
Transfer of health information to provider 100%
95.95%
4 pts better
Numerator 199 · Denominator 199
Transfer of health information to patient 100%
96.28%
3.7 pts better
Numerator 24 · Denominator 24
Resident COVID-19 vaccinations up to date 36.36%
25.2%
11.2 pts better
Numerator 44 · Denominator 121

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 98.2%
96.0%
2.2 pts better
93.4%
4.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.3% · Q3 96.4% · Q4 98.2% · 4Q avg 98.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100.0%
93.8%
6.2 pts better
95.5%
4.5 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury 4.0%
2.6%
1.4 pts worse
3.3%
0.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 5.0% · Q3 5.4% · Q4 3.5% · 4Q avg 4.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 11.4%
16.3%
4.9 pts better
11.4%
About the same
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.1% · Q3 17.0% · Q4 21.1% · 4Q avg 11.4%
Percentage of long-stay residents who lose too much weight 5.7%
5.8%
0.1 pts better
5.4%
0.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.3% · Q3 6.0% · Q4 9.3% · 4Q avg 5.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 13.4%
12.1%
1.3 pts worse
19.6%
6.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 10.5% · Q3 17.3% · Q4 12.7% · 4Q avg 13.4%
Percentage of long-stay residents who received an antipsychotic medication 11.1%
15.9%
4.8 pts better
16.7%
5.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 9.8% · Q3 10.9% · Q4 8.7% · 4Q avg 11.1% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 26.3%
20.0%
6.3 pts worse
16.3%
10 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 20.7%
15.8%
4.9 pts worse
14.9%
5.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 30.8% · Q3 24.0% · Q4 11.3% · 4Q avg 20.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.8%
1.2%
0.4 pts better
1.0%
0.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.5%
1.7%
1.2 pts better
1.7%
1.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 33.9%
23.5%
10.4 pts worse
19.8%
14.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 46.0% · Q2 34.2% · Q3 26.4% · Q4 28.9% · 4Q avg 33.9%
Percentage of long-stay residents with pressure ulcers 1.7%
4.7%
3 pts better
5.1%
3.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.1% · Q3 0.0% · Q4 1.4% · 4Q avg 1.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 94.4%
87.7%
6.7 pts better
81.7%
12.7 pts better
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 96.6% · Q3 92.5% · Q4 90.9% · 4Q avg 94.4%
Percentage of short-stay residents who had an outpatient emergency department visit 13.8%
13.2%
0.6 pts worse
12.0%
1.8 pts worse
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 14.0% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.1%
1.4%
0.3 pts better
1.6%
0.5 pts better
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.5% · Q3 1.0% · Q4 0.5% · 4Q avg 1.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 94.1%
82.0%
12.1 pts better
79.7%
14.4 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 17.5%
19.9%
2.4 pts better
23.9%
6.4 pts better
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 17.5% · Expected 23.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-18 · Fire 2025-06-18

13 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

11 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 2 Health 2024-02-22 · Fire 2024-02-22

14 health deficiencies

Top issue: Nutrition and Dietary (4 deficiencies)

10 fire-safety deficiencies

Top issue: Emergency Preparedness (3 deficiencies)

Cycle 3 Health 2022-01-13 · Fire 2022-01-13

5 health deficiencies

Top issue: Resident Rights (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-18

E20 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures including evacuation.

Corrected 2025-06-25

F · Potential for more than minimal harm 2025-06-18

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-06-25

F · Potential for more than minimal harm 2025-06-18

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2025-06-25

F · Potential for more than minimal harm 2025-06-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-06-25

F · Potential for more than minimal harm 2025-06-18

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-06-25

F · Potential for more than minimal harm 2025-06-18

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-06-25

F · Potential for more than minimal harm 2025-06-18

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-06-25

F · Potential for more than minimal harm 2025-06-18

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-06-25

F · Potential for more than minimal harm 2025-06-18

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-06-25

D · Potential for more than minimal harm 2025-06-18

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-06-25

D · Potential for more than minimal harm 2025-06-18

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-06-25

F · Potential for more than minimal harm 2024-02-22

E32 · Emergency Preparedness Deficiencies

Fire Safety

Provide primary/alternate means for communication.

Corrected 2024-03-27

F · Potential for more than minimal harm 2024-02-22

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2024-03-27

F · Potential for more than minimal harm 2024-02-22

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2024-03-27

F · Potential for more than minimal harm 2024-02-22

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-03-27

F · Potential for more than minimal harm 2024-02-22

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-03-27

F · Potential for more than minimal harm 2024-02-22

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2024-03-27

F · Potential for more than minimal harm 2024-02-22

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-03-27

F · Potential for more than minimal harm 2024-02-22

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-03-27

E · Potential for more than minimal harm 2024-02-22

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-03-27

D · Potential for more than minimal harm 2024-02-22

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-03-27

F · Potential for more than minimal harm 2022-01-13

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2022-01-27

E · Potential for more than minimal harm 2022-01-13

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2022-01-31

E · Potential for more than minimal harm 2022-01-13

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2022-01-27

D · Potential for more than minimal harm 2022-01-13

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-01-27

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-12-05

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2026-01-05

D · Potential for more than minimal harm 2025-12-05

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2026-01-05

E · Potential for more than minimal harm 2025-06-18

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2025-07-15

E · Potential for more than minimal harm 2025-06-18

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-07-15

E · Potential for more than minimal harm 2025-06-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-06-18

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-06-18

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-06-18

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-06-18

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-06-18

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-06-18

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-06-18

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2025-07-15

D · Potential for more than minimal harm 2025-06-02

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-06-25

D · Potential for more than minimal harm 2024-04-09

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2024-04-19

D · Potential for more than minimal harm 2024-04-09

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-04-19

D · Potential for more than minimal harm 2024-04-09

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-04-19

D · Potential for more than minimal harm 2024-04-09

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-04-19

F · Potential for more than minimal harm 2024-02-22

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2024-03-06

F · Potential for more than minimal harm 2024-02-22

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-22

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-22

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-22

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-03-16

D · Potential for more than minimal harm 2024-02-22

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-22

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-03-15

D · Potential for more than minimal harm 2024-02-22

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-03-22

D · Potential for more than minimal harm 2024-02-22

F810 · Nutrition and Dietary Deficiencies

Health

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Corrected 2024-03-22

D · Potential for more than minimal harm 2024-02-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-03-11

D · Potential for more than minimal harm 2023-06-05

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-06-20

G · Actual harm 2023-03-10

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-03-10

E · Potential for more than minimal harm 2022-01-13

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2022-02-07

E · Potential for more than minimal harm 2022-01-13

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-02-07

D · Potential for more than minimal harm 2022-01-13

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2022-02-07

Penalties and ownership

What sits behind the stars

Ownership

Pennant Healthcare LLC

5% Or Greater Direct Ownership Interest · Organization

100% 30 facilities 2024-09-11
The Ensign Group Inc

5% Or Greater Indirect Ownership Interest · Organization

100% 209 facilities 2024-09-11
Burnam, Soon

Corporate Officer · Individual

0% 323 facilities 2024-09-11
Farnsworth, Stephen

Corporate Director · Individual

0% 25 facilities 2024-09-11
Farnsworth, Stephen

Corporate Officer · Individual

0% 25 facilities 2024-09-11
Rackham, Michael

Operational/Managerial Control · Individual

0% 1 facilities 2025-03-01
Ross, Steve

Corporate Officer · Individual

0% 3 facilities 2024-09-11
Sato, Ami

Corporate Officer · Individual

0% 101 facilities 2024-09-11

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