Hearth Record

Peacehealth Southwest Medical Cente

An acute care hospital in Vancouver, Washington 98664

400 NE Mother Joseph Place, Vancouver, Washington 98664. (360) 256-2000.

CMS’s own record, on Care Compare

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The short answer

Record last released by CMS on Oct 20, 2026.

The last 24 months 2 deficiencies in 1 month of the last 36. Last cited Nov 2024. Most serious: Standard-level. Every month

Each figure’s source sits beside it, in its section below.

What these words mean3
Star ratings
CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
Inspection (survey)
A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
Deficiency, citation, violation
What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.

What did inspectors find?

The last inspection on record was on Nov 21, 2025: a complaint inspection.

2 deficiencies cited in the last three years.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

When those deficiencies happened

2 deficiencies in 1 month of the last 36. Last cited Nov 2024. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.

2 deficiencies by month over the last 3 years. Each cell is one month.
JanFebMarAprMayJunJulAugSepOctNovDec
2023 Dec
2024 JanFebMarAprMayJunJulAugSepOctNovDec
2025 JanFebMarAprMayJunJulAugSepOctNovDec
2026 JanFebMarAprMayJunJulAugSepOctNov

Hover or focus a month to read it.

No visit on record Visited, nothing cited A stronger orange is more serious, on its source’s own levels, read onto four bands: from the least serious it publishes to the most
Source:

Hearth Record drew this from the dates and levels in the source’s own records.

Each deficiency, as cited

Rule titles as CMS’s inspectors cite them, set in sentence case.

Source:

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Nov 15, 2024: complaint inspection2 deficiencies

  • Integration Of Outpatient Services

    The inspectors’ words, 657 words

    “INTEGRATION OF OUTPATIENT SERVICES CFR(s): 482.54(a) Outpatient services must be appropriately organized and integrated with inpatient services. This Standard is not met as evidenced by: 42597 . Based on interview, document review, and review of hospital policy and procedures, the hospital failed to ensure that staff took appropriate emergent action to respond to patient needs for 1 of 1 patients reviewed (Patient #1). Failure to ensure staff take appropriate immediate action to respond to a patient’s emergency medical needs risks delays in activating the hospital emergency response system and initiation of treatment. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Cardiopulmonary Resuscitation Code Blue,” PolicyStatID 16028862, approved 07/24, showed that: a. The purpose of the policy is to ensure the immediate provision of basic life support (BLS) and advanced cardiac life support (ACLS) by trained caregivers in the event of cardiopulmonary arrest anywhere on the hospital grounds of PeaceHealth Southwest Medical Center. b. The first responder will call for help and code team activation and will initiate basic life support (BLS) for the patient. c. All Code Blue documentation will be completed within the electronic medical record (EMR) by the Rapid Response Nurse (RRT). Document review of the hospital policy titled, “Cardiac Arrest (Code Blue) Procedure,” showed that the first responder will identify that the victim is unresponsive, breathless or pulseless, call for assistance and initiate BLS protocol. 2. On 11/14/24 at 10:55 AM the investigator and the Clinical Risk Management Director (Staff #1), a Risk Manager (Staff #2), the Chief Nursing Officer (Staff #3), the Surgical Services Director (Staff #4), the Surgical Services Manager (Staff #5), and the Rapid Response Team Manager (Staff #6) reviewed video footage recorded in the hospital’s main lobby on 09/11/24. The review showed: a. At 11:20 AM, Patient #1, sitting in a wheelchair accompanied by her mother and a staff member (Staff #8). b. At 11:21 AM, Patient #1’s body posture became limp, her head slumped backward, and her eyes closed. Patient #1 appeared to be unresponsive. Staff #8 did not assess Patient #1 for airway, breathing, or circulation (ABC), as prescribed by Basic Life Support (BLS) protocol. c. At 11:22 AM, Patient #1 briefly opened her eyes and straightened her head before her body posture again became limp with closed eyes and her head slumping to the side. Staff #1 did not perform an ABC assessment for Patient #1. d. At 11:24 AM, Patient #1’s still appeared unresponsive. Patient #1’s father came through the hospital entrance doors, looked at Patient #1, appeared to say something, and rushed away. Staff #8 did not perform an ABC assessment for Patient #1. e. At 11:26 AM, two unidentified staff members pushing a code cart (cart containing emergency resuscitation supplies) arrived. No staff member performed an ABC assessment for Patient #1. Two unidentified staff members pushed Patient #1 in the wheelchair out of the hospital entrance as rapid response team members appeared on scene. 3. On 11/14/24 between 9:30 AM and 11:00 AM, the investigator conducted a group interview with the Clinical Risk Management Director (Staff #1), a Risk Manager (Staff #2), the Chief Nursing Officer (Staff #3), the Surgical Services Director (Staff #4), the Surgical Services Manager (Staff #5), and the Rapid Response Team Manager (Staff #6). The interview showed: a. Staff #1 had current Basic Life Support (BLS) certification. b. It is an expectation that BLS certified staff perform ABC assessments for unresponsive patients in emergent situations. c. It is an expectation that the Code Blue team respond to patient emergencies in the hospital main lobby. It was unclear which staff member called for a rapid response rather than a Code Blue (emergent response for any person who might be experiencing cardiac arrest). d. There was no documentation of the Rapid Response or Code Blue event prior to Patient #1’s arrival in the Emergency Department. e. The hospital does not hold Code Blue drills for public areas. .”

    Rule A1077. Standard-level. From a complaint.

  • Standard Tag For Outpatient Services

    The inspectors’ words, 225 words

    “STANDARD TAG FOR OUTPATIENT SERVICES CFR(s): 482.54 Standard-level Tag for §482.54 Condition of Participation: Outpatient Services If the hospital provides outpatient services, the services must meet the needs of the patients in accordance with acceptable standards of practice. This Standard is not met as evidenced by: 42597 . Based on interviews, document review, and review of hospital policy and procedures, the hospital failed to implement its policies and procedures to ensure that post-anesthesia care (PACU) registered nurses (RNs) documented a full set of vital signs prior to discharge for 1 of 4 same day surgery patients (Patient #1) reviewed. Failure to ensure that staff follow approved policies and procedures for patient discharge risks unsafe discharge and patient harm. Findings included: 1. Review of the hospital document titled, “PeaceHealth Nursing Care Standards (NCS) 2024,” no #, no date, showed that RNs will assess and document patients’ blood pressure, heart rate, respiratory rate, SpO2 (oxygen saturation), and temperature prior to discharge. 2. The investigator reviewed Patient #1’s medical record created on 09/11/24. The review showed that Patient #1 had no respiratory rate documented prior to discharge. 3. On 11/14/24 at 2:30 PM, the investigator interviewed the Surgical Services manager (Staff #4), who confirmed the missing information and stated that taking and documenting a full set of patient vital signs prior to discharge is a department expectation. .”

    Rule A1081. Standard-level. From a complaint.

All 4 inspections in the last three years
Inspections on record
DateVisitWhat the record says
Nov 21, 2025Complaint inspectionNo deficiencies cited
Sep 19, 2025Complaint inspectionNo deficiencies cited
Nov 18, 2024Complaint inspectionNo deficiencies cited
Nov 15, 2024Complaint inspection2 deficiencies cited

How do patients fare?

  • CMS’s overall for it is 3 of 5.
  • Of the measures behind its , CMS counts against the national value: mortality, 0 better and 0 worse of 8; safety of care, 1 better and 1 worse of 7; readmission, 1 better and 1 worse of 11.
  • Patients rate it 3 of 5 in CMS’s patient survey (459 surveys completed, Oct 1, 2024 to Sep 30, 2025): 67% rated it 9 or 10 out of 10, and 69% would definitely recommend it.
  • Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), better than the national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; surgical site infections after colon surgery, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
  • CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
  • Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 13.3%, heart failure 10.9%, pneumonia 14.2%, COPD 7.7%, stroke 10.3%, heart bypass surgery 2%. CMS gives no comparison with the national rate for them in this release.
  • Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 14%, heart failure 17.8%, pneumonia 16.3%, COPD 19.5%, heart bypass surgery 11.1%, hip or knee replacement 4%. CMS gives no comparison with the national rate for them in this release.
  • After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
  • Emergency department patients spent a median of 275 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 3% left before being seen.
  • 52% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
  • Medicare’s spending per patient here is 0.9 times the national median (Jan 1, 2024 to Dec 31, 2024).
Source:

CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.

CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.

Ratings and measures, as published
MeasureRating
Overall ratingCMS’s overall hospital quality star rating, 1 to 53 of 5
Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 53 of 5

Is it certified, and in good standing?

  • Medicare-certified acute care hospital since Jul 1, 1966.
  • Ownership: voluntary non-profit - private.
  • It is accredited by DNV, whose surveys stand in for the state’s routine inspections.
  • No deficiency on record in the last three years.
  • It has an inpatient rehabilitation unit of 14 beds, which CMS lists apart as a rehabilitation facility.
  • Voluntary non-profit - Private.
Source:

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

Has it been penalized?

  • CMS doesn’t publish fines or other penalties for hospitals.
  • Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
  • 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.
Source:

CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.

What do patients say about their care?

  • CMS doesn’t publish staffing levels for hospitals.
  • In CMS’s patient survey, patients rate how well its nurses communicated 3 of 5.
  • 81% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
Source:

CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.

Who owns it?

  • Peacehealth owns 100% directly since Jan 1, 2013.
  • 20 owners or officers are people: Charlotte Virgia Davenport (corporate director, 0%); Ione S Adams (corporate director, 0%); Leonard W Kearney (corporate director, 0%); Thomas Karnes (corporate officer, 0%); Lorraine Arvin (corporate director, 0%); Danny W Hollingshead (corporate director, 0%); Richard Harry Wollenberg (corporate director, 0%); Timothy Ackman (corporate director, 0%); Carolyn Aaron (corporate director, 0%); Arthur Craig Springer II (corporate officer, 0%); Linda Lea Jackson (corporate director, 0%); Linda Lea Jackson (managing employee (on the payroll), 0%); Richard E Magnuson (corporate officer, 0%); Mary Mcwilliams (corporate director, 0%); Kathleen Lee Pruitt (corporate officer, 0%); Sheila Lemieux (corporate director, 0%); Sarah Marie Ness (corporate officer, 0%); Andrea C Nenzel (corporate director, 0%); Karl Joseph Carrier (corporate director, 0%); Donna King (corporate director, 0%).
  • CMS’s Provider of Services file records 2 changes of ownership, the latest on Jan 1, 2013.
  • No private-equity firm among the owners CMS lists.
  • No real-estate investment trust among the owners CMS lists.
Source:

CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.

CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.

Organisations CMS lists
OrganisationRoleShareSince
PeacehealthOwns 5% or more directly100%Jan 1, 2013

How does it compare nearby?

  • Of the 3 hospitals CMS lists in Clark County, 2 have an overall star rating from CMS: 1 rated 4 of 5, 1 rated 3 of 5.
  • CMS rates this one 3 of 5.
Source:

CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.

2 compared
PlaceOverall star rating
Legacy Salmon Creek Medical Center4
Rainier SpringsNot given

What the record doesn’t say

  • CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
  • Only complaints that led to a citation appear; complaints that didn’t aren’t published.
  • Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
  • QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
  • CMS doesn’t publish staffing levels for hospitals.
  • In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.

Sources

If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.

Source:

This copy of the record was made on Nov 5, 2026.

From the hospital

The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.

Replies

None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.

Paid listing

None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.

How to read a record

Four things every record does, shown on an example record made up for this guide.

An example record, made up for this guide

An example nursing home

Made up for this guide: no real place is shown

Not fully inspected in over two years (CMS flag)

11 health citations at the latest inspection cycle

The state average is 14.3.

Source:

CMS, State and US Averages and Health Deficiencies. Released Oct 28, 2026. Updated monthly.

From the homeNone yet. Replies and paid listings aren’t open, and when they open they will sit here, below the record.

1 of 4

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