Inspection Reports for South Hill Village
3117 E Chaser Ln, Spokane, WA 99223, United States, WA
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Census Over Time
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 4, 2025
Visit Reason
The Department of Social and Health Services conducted a complaint investigation at South Hill Village, Assisted Living & Memory Care on September 4, 2025, which resulted in the imposition of a civil fine due to violations found.
Findings
The licensee failed to ensure a safe medication system was in place for one resident, resulting in medications not being given as prescribed and placing the resident at risk for health complications. This deficiency was recurring, having been previously cited multiple times.
Complaint Details
The visit was complaint-related and substantiated, resulting in a civil fine of $1,000 for violation of WAC 388-78A-2210 (1)(b)(2)(a) Medication services. The deficiency was recurring with prior citations on January 15, 2025, March 15, 2024, and June 23, 2023.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a safe medication system for one resident, resulting in medications not being given as prescribed. |
Report Facts
Civil fine amount: 1000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the imposition of civil fine letter |
| Stephanie Jenks | Field Manager | Contact person for plan of correction and questions |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Sep 4, 2025
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation regarding medication errors by the facility.
Findings
The investigation found that the facility failed to follow its policy on handling new physician orders, resulting in a resident not receiving medication as ordered by their primary care provider. A deficiency was cited under Washington administrative code (WAC) 388-78a-2210(1)(b)(2)(a).
Complaint Details
The complaint involved medication errors by the facility. The investigation substantiated a failed provider practice with citation(s) written.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a safe medication system leading to a resident not receiving medication as ordered by their physician. |
Report Facts
Total residents: 101
Resident sample size: 4
Closed records sample size: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra Fast | Community Complaint Investigator | Investigator who conducted the complaint investigation and on-site verification |
Inspection Report
Follow-Up
Census: 95
Deficiencies: 14
May 2, 2025
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility on 05/02/2025 to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements. Previous deficiencies related to medication availability and administration were corrected.
Complaint Details
The inspection was a follow-up to a complaint investigation involving multiple residents and allegations of medication errors, abuse, inadequate training, and failure to maintain proper records. The complaint investigation was unannounced and involved review of 15 of 99 residents.
Deficiencies (14)
| Description |
|---|
| Nonavailability of medications resulting in Resident 16 not receiving medication for 4 days, placing the resident at risk of infection. |
| Failure to ensure residents received medications as prescribed, contributing to Resident 15 developing symptoms and requiring hospital admission. |
| Failure to update residents' negotiated service agreements and involve residents in planning services. |
| Failure to investigate, document, and protect residents from alleged abuse, resulting in Resident 14 feeling defenseless and at risk of harm. |
| Failure to complete facility orientation and ensure staff had required certifications, placing residents at risk of care from unqualified individuals. |
| Failure to ensure staff completed specialized training for developmental disabilities, mental illness, and dementia, resulting in residents receiving care from untrained staff. |
| Failure to provide a full assessment for residents within 14 days of admission, placing residents at risk of unmet care needs. |
| Failure to maintain updated resident records and medication lists, resulting in risk of medication errors and lack of continuity of care. |
| Failure to allow residents to control and secure their medications, including inhalers, resulting in residents not having access to prescribed medications. |
| Failure to ensure negotiated service agreements were signed by residents or representatives, placing residents at risk of unmet care needs. |
| Failure to provide adequate food and nutrition assistance to residents, resulting in unmet nutritional needs and lack of support. |
| Failure to obtain and maintain written family assistance plans for medication administration, placing residents at risk of medical complications. |
| Failure to report incidents of alleged abuse timely, delaying investigation and placing residents at risk of harm. |
| Failure to complete annual self-medication assessments for residents, resulting in residents not being assessed for safe medication administration. |
Report Facts
Residents sampled: 6
Residents sampled: 15
Missed medication days: 4
Missed medication doses: 5
Staff without completed orientation: 5
Residents with unmet negotiated service plan signatures: 14
Residents with unmet family assistance plans: 1
Residents with missed meals: 1
Residents without annual self-medication assessment: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joy Pipgras | LTC Surveyor | Department staff who did the on-site verification and participated in inspections. |
| Brian Zbylski | ALF Licensor | Department staff who inspected the Assisted Living Facility. |
| Stephanie Jenks | Community Field Manager | Signed the follow-up inspection letter. |
| Kari Miller | Administrator | Facility administrator who signed attestation statements on multiple deficiencies. |
| Staff Q | Medication Technician | Interviewed regarding medication administration for Resident 16. |
| Staff P | Health and Wellness Director/RN | Interviewed regarding medication administration for Resident 16. |
| Staff J | Regional Health and Wellness Director | Interviewed regarding hospitalizations and medication issues for Resident 15 and other findings. |
| Staff L | Resident Care Coordinator | Documented bruising incident and reporting process. |
| Staff F | Care Partner | Personnel record reviewed for orientation and certification. |
| Staff C | Care Partner | Personnel record reviewed for orientation and certification. |
| Staff D | Care Partner/Med Aide | Personnel record reviewed for orientation and certification. |
| Staff H | Care Partner/Med Aide | Observed giving medication and interviewed regarding training. |
| Staff K | Assistant Executive Director | Interviewed regarding staff certification timelines. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 15, 2025
Visit Reason
The Department of Social and Health Services completed a Full Inspection and Complaint Investigation at South Hill Village, Assisted Living & Memory Care on January 15, 2025, due to concerns related to medication services.
Findings
The licensee failed to ensure residents received their medication as prescribed for one resident, which contributed to the resident developing symptoms and requiring hospital admission. This deficiency was recurring, previously cited in June 2023 and March 2024.
Complaint Details
The visit was complaint-related and substantiated by the finding that medication services were not properly administered, resulting in harm to one resident.
Deficiencies (1)
| Description |
|---|
| Failure to ensure residents received their medication as prescribed for one resident. |
Report Facts
Civil fine amount: 600
Previous citation dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the letter regarding the civil fine and inspection findings. |
| Jessica Salquist | Regional Administrator | Contact person for submission of Plan of Correction and inquiries. |
Inspection Report
Life Safety
Deficiencies: 19
Nov 22, 2024
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at South Hill Village, Assisted Living & Memory Care facility to assess compliance with fire protection and safety codes.
Findings
The inspection identified multiple deficiencies related to fire safety including lack of documentation for semi-annual hood cleaning, annual fire wall inspection, fire sprinkler testing, kitchen suppression system servicing, fire extinguisher inspections, fire alarm testing and maintenance, smoke detector sensitivity testing, and fire drills. Several fire doors and exit doors failed to close or latch properly, and some fire extinguishers and fire alarm pull stations were obstructed or not inspected. The facility was disapproved due to these deficiencies.
Deficiencies (19)
| Description |
|---|
| Facility is unable to provide documentation for the semi-annual hood cleaning for the last 24 months. |
| Facility is unable to provide documentation that the annual fire wall inspection has been completed. |
| Swinging fire doors did not close and latch automatically; multiple doors failed testing including repeat violations of propped open doors. |
| On the 1st floor laundry room there is a ceiling vent cover missing. |
| Facility is unable to provide documentation for the annual dry system trip test and quarterly sprinkler system testing. |
| Facility is unable to provide documentation for the semi-annual kitchen suppression system servicing for the first half of 2024. |
| Fire extinguisher in westside elevator mechanical room has not had monthly inspection completed for October. |
| Fire extinguisher in 3rd floor community room is blocked by storage (trashcan). |
| Fire alarm manual pull station on 1st floor private dining room is obstructed by storage (plant). |
| Facility is unable to provide documentation for annual fire alarm system testing and maintenance. |
| Facility is unable to provide documentation for required smoke detector sensitivity testing. |
| Facility is unable to provide documentation for monthly carbon monoxide detector maintenance. |
| On every floor in common area there is a fuel burning fireplace with no carbon monoxide detection installed. |
| On the 2nd floor exit sign number 29 is missing the front of the sign/powerback. |
| Facility failed to provide records showing monthly 30 second emergency egress lighting activation tests. |
| Facility failed to provide documentation indicating annual 90-minute battery backup light test within last 12 months. |
| Facility unable to provide documentation for 4-year fire and smoke damper inspection. |
| Facility unable to provide documentation that annual fire door inspection has been completed. |
| Facility cannot provide documentation for completion of twelve planned and unannounced fire drills in previous 12 months; multiple quarters missing drills. |
Report Facts
Inspection date: Nov 22, 2024
Next inspection scheduled: Dec 27, 2024
Next inspection scheduled: Dec 31, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara R. McMullen | Deputy State Fire Marshal | Signed and digitally signed the inspection reports |
| Shane Miller | Maintenance Director | Signed as Owner or Authorized Representative |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 30, 2024
Visit Reason
The Department completed a follow-up inspection of the Assisted Living Facility to verify correction of previously cited deficiencies.
Findings
The follow-up inspection found no deficiencies and confirmed that the facility meets the Assisted Living Facility licensing requirements.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Amy Wright | NCI Complain Investigator | Department staff who did the on-site verification during the follow-up inspection. |
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 1
May 29, 2024
Visit Reason
The Department completed a complaint investigation of the Assisted Living Facility triggered by complaint number 130803 regarding medication availability.
Findings
The facility had a delay in medication availability for one resident due to an order discrepancy. Staff were re-educated on medication availability and processes, and the resident received prescribed medication as ordered. Residents interviewed reported no concerns and were observed without distress during the unannounced visit.
Complaint Details
Complaint investigation related to medication availability; complaint number 130803; investigation conducted from 05/22/2024 through 05/29/2024; substantiation indicated by failed provider practice and citation(s) written.
Deficiencies (1)
| Description |
|---|
| Delay of medication availability due to a discrepancy with the order |
Report Facts
Total residents: 143
Resident sample size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anne Sinclair | NCI Community Complaint Investigator | Investigator who conducted the complaint investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Mar 15, 2024
Visit Reason
The Department of Social and Health Services conducted a complaint investigation at South Hill Village, Assisted Living & Memory Care on March 15, 2024, due to concerns about medication services.
Findings
The licensee failed to provide medications as prescribed for one resident, resulting in medication errors that contributed to elevated blood pressure and placed the resident at risk of health complications. This deficiency was recurring, previously cited on June 23, 2023.
Complaint Details
The visit was complaint-related and substantiated, resulting in a civil fine of $200 for medication service violations.
Deficiencies (1)
| Description |
|---|
| Failure to provide medications as prescribed for one resident, resulting in medication errors and elevated blood pressure. |
Report Facts
Civil fine amount: 200
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the letter regarding the civil fine and complaint investigation |
| Stephanie Jenks | Field Manager | Contact person for plan of correction and appeals |
Inspection Report
Complaint Investigation
Census: 93
Deficiencies: 1
Mar 7, 2024
Visit Reason
The inspection was conducted as an unannounced on-site complaint investigation triggered by an allegation that a resident's medication was not given as prescribed.
Findings
The investigation found that the facility failed to provide medications as prescribed for one sampled resident, resulting in medication errors that contributed to elevated blood pressure and placed the resident at risk of health complications. The deficiency was a recurring issue previously cited.
Complaint Details
The complaint alleged that a resident's medication was not given as prescribed. The investigation substantiated the allegation with a failed provider practice identified and citation(s) written.
Deficiencies (1)
| Description |
|---|
| Facility failed to provide medications as prescribed for one resident, resulting in medication errors related to losartan dosage and blood pressure parameters. |
Report Facts
Total residents: 93
Resident sample size: 6
Days blood pressure over 140/90 in January: 13
Days blood pressure over 140/90 in February: 13
Days losartan given in February: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anne Sinclair | NCI Community Complaint Investigator | Investigator who conducted the complaint investigation and follow-up inspection |
| Staff A | Medication Tech | Interviewed regarding medication administration and acknowledged missed medication parameters |
| Staff B | Health and Wellness Director | Interviewed and confirmed medication errors related to losartan dosage and blood pressure parameters |
| Staff C | Resident Care Coordinator | Verified medication prescription and parameters for Resident 1 |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 1
Jan 10, 2024
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation that as needed medication was not given when requested.
Findings
The investigation found that a facility staff member did not administer an as needed medication to a resident, resulting in the resident experiencing pain. The staff member was removed from medication administration and provided education. The facility had protocols in place and took corrective actions including staff retraining and identifying barriers to medication administration.
Complaint Details
Complaint number 111251 regarding failure to administer as needed medication when requested was substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to administer as needed medication to a resident as prescribed, resulting in resident pain. |
Report Facts
Total residents: 99
Resident sample size: 6
Compliance Determination Number: 34734
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anne Sinclair | NCI Community Complaint Investigator | Investigator who conducted the complaint investigation and provided consultation |
Inspection Report
Enforcement
Deficiencies: 6
Aug 17, 2023
Visit Reason
The Department of Social and Health Services conducted a follow-up visit to South Hill Village Assisted Living & Memory Care to assess compliance and impose civil fines based on violations of state regulations.
Findings
The facility was cited for multiple uncorrected deficiencies including failure to monitor residents' well-being, ensure pets' immunizations, maintain tuberculosis test records for staff, obtain signed negotiated service agreements, perform safety assessments, and ensure proper nursing services. These deficiencies placed residents at risk of harm and resulted in civil fines totaling $2,000.
Deficiencies (6)
| Description |
|---|
| Failed to identify, assess, evaluate, and address the changing needs of two residents, placing them at risk of harm and health complications. |
| Failed to ensure two residents’ pets were current with their immunizations, placing residents at risk of illness or injury. |
| Failed to maintain tuberculosis test record results for two staff, risking resident exposure to tuberculosis. |
| Failed to ensure negotiated service agreements were signed by five residents or their representatives, risking unmet care needs. |
| Failed to perform a safety assessment for one resident with medical devices, risking injury due to unsafe equipment use. |
| Failed to obtain written consent for nurse delegation for one resident and ensure insulin administration and blood sugar monitoring by qualified staff for two residents, risking unsafe diabetic care. |
Report Facts
Civil fines total: 2000
Residents with unsigned service agreements: 5
Residents with pets lacking immunizations: 2
Staff without tuberculosis test records: 2
Residents with nurse delegation consent issues: 1
Residents receiving nurse delegation services without proper supervision: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Jenks | Field Manager | Contact person for plan of correction and appeals |
| Matt Hauser | Compliance Specialist | Signed the enforcement letter |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 23, 2023
Visit Reason
The Department of Social and Health Services completed a full and complaint investigation at South Hill Village, Assisted Living & Memory Care on June 23, 2023, resulting in a civil fine due to violations related to monitoring residents' well-being.
Findings
The licensee failed to evaluate and monitor a resident after an incident that exacerbated a back injury, placing the resident at risk of not receiving proper care and services. This deficiency was recurring from a previous citation on March 22, 2022.
Complaint Details
The visit was complaint-related and resulted in substantiated violations leading to a civil fine.
Deficiencies (1)
| Description |
|---|
| Failure to evaluate and monitor a resident after an incident resulting in exacerbation of a back injury. |
Report Facts
Civil fine amount: 300
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Hauser | Compliance Specialist | Signed the letter regarding the civil fine and inspection findings. |
| Stephanie Jenks | Field Manager | Contact person for plan of correction and questions related to the inspection. |
Inspection Report
Life Safety
Deficiencies: 11
Dec 23, 2022
Visit Reason
The Office of the State Fire Marshal conducted a fire safety inspection at the South Hill Village Assisted Living & Memory Care facility to assess compliance with fire protection codes and regulations.
Findings
The inspection found multiple fire safety code requirements either corrected on site or in progress, including issues with multipug adapters, power supply, installation of power taps, extension cords, unapproved conditions, penetrations, opening protectives, door operation, sprinkler system maintenance, portable fire extinguishers, and fire drills. Some violations were corrected immediately, while others were scheduled for correction.
Deficiencies (11)
| Description |
|---|
| Multipug adapters, such as cube adapters, unfused plug strips or any other device not complying with NFPA 70 shall be prohibited. |
| Relocatable power taps shall be directly connected to a permanently installed receptacle. |
| Relocatable power tap cords shall not extend through walls, ceilings, floors, under doors or floor coverings, or be subject to environmental or physical damage. |
| Extension cords and flexible cords shall not be a substitute for permanent wiring and shall be listed and labeled in accordance with UL 817. |
| Open junction boxes and open-wiring splices shall be prohibited. Approved covers shall be provided for all switch and electrical outlet boxes. |
| Materials and firestop systems used to protect membrane and through penetrations in fire-resistance-rated construction shall be maintained and securely attached with no openings visible. |
| Opening protectives shall be maintained in an operative condition in accordance with NFPA 80. |
| Swinging fire doors shall close from the full-open position and latch automatically. |
| Sprinkler systems shall be tested and maintained in accordance with Section 901 and freeze protection maintained at minimum 40 degrees. |
| Portable fire extinguishers shall be selected, installed and maintained in accordance with NFPA 10. |
| At least twelve planned and unannounced fire drills shall be held every year and documented. |
Report Facts
Inspection date: Dec 23, 2022
Next inspection scheduled: Dec 31, 2023
Next inspection scheduled: Dec 18, 2022
Missing fire drills: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Barbara McMullen | Deputy State Fire Marshal | Signed inspection reports and listed as Deputy State Fire Marshal |
Report
File
R_South_Hill_Village,_Assisted_Living_&_Memory_Care_Inspection_06-23-2023_-_EL.pdf
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