Agility Health and Rehab: ROM Program Failures - WA
That resident, identified in inspection records only as Resident 24, came to the facility with a stiff, immobile left knee, uncontrolled diabetes, and generalized muscle weakness. Physical therapists who worked with them wrote a clear discharge recommendation: begin a restorative range-of-motion program for both lower extremities. The care plan, initiated December 25, 2025, contained no such program. When inspectors interviewed Resident 24 on June 4, 2026, the resident said they had been told an exercise program was coming after physical therapy ended. They said they had never been offered one.
The Director of Rehabilitation, identified in the report as Staff D, confirmed it plainly during an interview the following day. The facility had failed to initiate and implement the restorative program after Resident 24's physical therapy discharge.
That was one resident. The second case involved a different kind of failure.
Resident 112 came to the facility with diabetes, weakness, and hemiplegia affecting the right side of the body, meaning partial loss of strength and near-complete loss of voluntary movement. An order in their chart directed staff to apply a right elbow extension splint each morning for up to six hours, three to six times per week. The goal was to maintain or improve range of motion in a limb the resident could barely control on their own.
On June 3 and again on June 4, inspectors observed the splint sitting on a corner table in the resident's room. It was not on the resident.
A progress note dated June 4 explained why. Staff had discontinued the restorative program and the splinting, citing the resident's refusals. The care plan had been updated accordingly. The program was gone.
But the restorative flow sheet told a more complicated story. Between May 14 and June 4, Resident 112 had refused splint assistance on three occasions. On those same records, documentation showed the resident was re-approached by alternate staff and agreed to wear the splint. The restorative aide assigned to Resident 112, identified as Staff Y, told inspectors they had no personal experience with the resident refusing. Staff Y said the most effective approach was simply explaining that the splint would not be painful.
Three refusals in roughly three weeks, a resident who responded to a different approach, and the program was still canceled.
Staff D, the Director of Rehabilitation, addressed this directly when inspectors asked. Three refusals in 30 days, Staff D said, was uncommon grounds for discontinuing a restorative program. It did not meet expectations, Staff D said, that the program had been stopped for that reason.
The inspection, conducted June 9, 2026, identified both failures under a standard requiring facilities to ensure residents with limited range of motion receive the services necessary to maintain their functioning. Inspectors rated the level of harm as minimal harm or potential for actual harm, and noted that few residents were affected. The risk they identified, though, was specific: further decline in range of motion, increased dependence, pain, and a diminished quality of life.
For Resident 24, the path forward from physical therapy was supposed to be a restorative program. Instead it was nothing, for months, while a stiff knee stayed stiff and weakened muscles stayed weak.
For Resident 112, a splint designed to preserve what little voluntary movement remained in a partially paralyzed arm sat on a corner table while the resident's elbow went unsupported. The aide who knew how to get the resident to agree was not the one who decided to stop trying.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Agility Health and Rehabilitation from 2026-06-09 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
AGILITY HEALTH AND REHABILITATION in UNIVERSITY PLACE, WA was cited for violations during a health inspection on June 9, 2026.
Physical therapists who worked with them wrote a clear discharge recommendation: begin a restorative range-of-motion program for both lower extremities.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.