Cycle 1
Health 2025-01-13 · Fire 2025-01-13
3 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Spokane, WA
Touchmark On South Hill Nursing
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2929 South Waterford Drive, Spokane, WA
(509) 536-2929
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
57
Certified beds
Average residents
2
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-08-26
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
1,772
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.08
Composite VBP score used to determine payment impact.
Payment multiplier
1.0089
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.63
Baseline 18.27% · Performance 17.43% · Measure score 8.63 · Achievement 8.63 · Improvement 6.25
Healthcare-associated infections
7.43
Baseline 6.40% · Performance 5.61% · Measure score 7.43 · Achievement 7.43 · Improvement 5.09
Total nurse turnover
0
Baseline 68.89% · Performance 75.00% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.57
Baseline 4.47 hours · Performance 4.66 hours · Measure score 5.57 · Achievement 5.57 · Improvement 0.96
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.47% |
10.72%
2.2 pts better
|
No Different than the National Rate · Eligible stays 338 · Observed rate 5.33% · Lower 95% interval 6.16% |
| Discharge to community | 71.01% |
50.57%
20.4 pts better
|
Better than the National Rate · Eligible stays 358 · Observed rate 69.83% · Lower 95% interval 66.79% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 167 · Denominator 167 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 167 |
| Discharge self-care score | 81.95% |
53.69%
28.3 pts better
|
Numerator 109 · Denominator 133 |
| Discharge mobility score | 73.68% |
50.94%
22.7 pts better
|
Numerator 98 · Denominator 133 |
| Pressure ulcers or injuries, new or worsened | 5.99% |
2.29%
3.7 pts worse
|
Numerator 10 · Denominator 167 · Adjusted rate 7.34% |
| Healthcare-associated infections requiring hospitalization | 5.61% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 192 · Observed rate 3.13% · Lower 95% interval 3.36% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 66 |
| Staff flu vaccination coverage | 4.21% |
42%
37.8 pts worse
|
Numerator 4 · Denominator 95 |
| Discharge function score | 71.43% |
56.45%
15 pts better
|
Numerator 95 · Denominator 133 |
| Transfer of health information to provider | 96.55% |
95.95%
0.6 pts better
|
Numerator 28 · Denominator 29 |
| Transfer of health information to patient | 97.5% |
96.28%
1.2 pts better
|
Numerator 117 · Denominator 120 |
| Resident COVID-19 vaccinations up to date | 43.75% |
25.2%
18.6 pts better
|
Numerator 35 · Denominator 80 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.2% |
96.0%
7.8 pts worse
|
93.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 88.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.6%
2.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
16.3%
16.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 35.5% |
5.8%
29.7 pts worse
|
5.4%
30.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
12.1%
0.4 pts worse
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.1% |
15.9%
10.2 pts worse
|
16.7%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.1% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.8% |
15.8%
2 pts better
|
14.9%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.1% |
1.2%
1.9 pts worse
|
1.0%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 46.1% |
23.5%
22.6 pts worse
|
19.8%
26.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 46.1% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
4.7%
2.9 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
87.7%
5.1 pts better
|
81.7%
11.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 92.3% · Q3 95.6% · Q4 95.3% · 4Q avg 92.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
13.2%
0.3 pts better
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 11.2% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.4%
0.1 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.6% · Q3 1.8% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.4% |
82.0%
7.4 pts better
|
79.7%
9.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
19.9%
0.1 pts worse
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 15.9% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-31 · Fire 2023-08-31
21 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-03-31 · Fire 2022-03-31
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-07
F · Potential for more than minimal harm
2025-01-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-22
F · Potential for more than minimal harm
2025-01-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-07
E · Potential for more than minimal harm
2025-01-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-07
F · Potential for more than minimal harm
2023-08-31
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-31
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-08-31
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-30
D · Potential for more than minimal harm
2023-08-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-30
F · Potential for more than minimal harm
2022-03-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-05-10
F · Potential for more than minimal harm
2022-03-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-22
D · Potential for more than minimal harm
2022-03-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-04-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-13
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-13
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 2025-02-11
D · Potential for more than minimal harm
2025-01-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-11
E · Potential for more than minimal harm
2024-08-22
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-10-02
E · Potential for more than minimal harm
2024-08-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-02
D · Potential for more than minimal harm
2024-08-22
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 2024-10-02
D · Potential for more than minimal harm
2024-08-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-02
E · Potential for more than minimal harm
2024-06-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-05
E · Potential for more than minimal harm
2024-06-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-05
D · Potential for more than minimal harm
2024-04-08
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 2024-04-23
D · Potential for more than minimal harm
2024-04-08
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 2024-04-23
E · Potential for more than minimal harm
2024-02-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-18
F · Potential for more than minimal harm
2023-08-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-11
F · Potential for more than minimal harm
2023-08-31
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-10-11
E · Potential for more than minimal harm
2023-08-31
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 2023-10-11
E · Potential for more than minimal harm
2023-08-31
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 2023-10-11
D · Potential for more than minimal harm
2023-08-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-31
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-31
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-31
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-31
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-11
D · Potential for more than minimal harm
2023-08-31
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 2023-10-11
D · Potential for more than minimal harm
2023-08-31
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 2023-10-11
D · Potential for more than minimal harm
2023-08-31
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 2023-10-11
D · Potential for more than minimal harm
2022-03-31
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2022-05-06
D · Potential for more than minimal harm
2022-03-31
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-05-06
D · Potential for more than minimal harm
2022-03-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-05-06
D · Potential for more than minimal harm
2022-03-31
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 2022-05-06
D · Potential for more than minimal harm
2022-03-31
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-05-06
Penalties and ownership
What sits behind the stars
Ownership
Bair, Jeffrey
5% Or Greater Direct Ownership Interest · Individual
Bair, Jeffrey
Corporate Director · Individual
Bair, Jeffrey
W-2 Managing Employee · Individual
Colleen T And Werner G Nistler Jr Family Trust
5% Or Greater Direct Ownership Interest · Organization
Colleen T And Werner G Nistler Jr Family Trust
General Partnership Interest · Organization
Mcgaughey, Meagan
W-2 Managing Employee · Individual
Nistler, Colleen
5% Or Greater Direct Ownership Interest · Individual
Nistler, Colleen
General Partnership Interest · Individual
Nistler, Colleen
Corporate Director · Individual
Nistler, Werner
5% Or Greater Direct Ownership Interest · Individual
Nistler, Werner
General Partnership Interest · Individual
Nistler, Werner
Corporate Director · Individual
Pryor, Brian
5% Or Greater Direct Ownership Interest · Individual
Pryor, Brian
Corporate Director · Individual
Touchmark Living Centers, Inc.
General Partnership Interest · Organization
Touchmark Living Centers, Inc.
Operational/Managerial Control · Organization
Touchmark, LLC
5% Or Greater Direct Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Alderwood Manor
Spokane, WA
3-star overall rating with 2-star inspections with $32,214 in total fines with 23 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
South Hill Rehabilitation And Care Center
Spokane, WA
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Spokane Veterans Home
Spokane, WA
5-star overall rating with 4-star inspections with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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