Agility Health And Rehabilitation
AGILITY HEALTH AND REHABILITATION in UNIVERSITY PLACE, WA — inspection on November 25, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the September 2025 MAR showed a 07/07/2025 order to encourage the resident to be up out of bed and in wheelchair for all meals: document acceptance vs refusal before meals. On 09/06/2025 5:30 PM staff documented refusal.
During an interview on 09/19/2025 at 2:59 PM Staff H, LPN, stated Resident 3 was diagnosed with COVID-19, so they were in the room with the door closed, on a bariatric size (for plus sized residents) mattress.
Staff H stated they had never seen Resident 3 kick their feet off the bed, or sit up on the edge of the bed, and they had no idea how the resident got out of bed.During an interview on 09/19/2025 at 1:38 PM, Staff B acknowledged the investigation was incomplete.REFER TO: WAC 388-97-640(2)(5)(6)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Agility Health and Rehabilitation
5520 Bridgeport Way West University Place, WA 98467
SUMMARY STATEMENT OF DEFICIENCIES
oxygen therapy, experienced shortness of breath with exertion and when lying flat.
Review of the 03/11/2025 COPD CP showed the resident was using O2 at 2 lpm via NC, had a CPAP at night, and increased nasal saline gel for dry nares related to O2 with humidifier.On 09/19/2025 at 11:45 AM Resident 8 was observed with O2 running at 2.5 lpm through a NC from an O2 concentrator.
The tubing was dated 09/15/2025.
The humidifier was dated 09/08/2025 and empty. In an interview at this time, Resident 8 stated that COPD was a new diagnosis for them, they were having trouble keeping the CPAP on at night, but when it was able to stay on, they woke up feeling great.
Review of the September 2025 TAR showed 01/19/2025 orders to change O2 tubing, concentrator bottle (if needed) and clean filter every week every night shift every Sunday which was documented as done night shift of 09/07/2025 and 09/14/2025.Further review of the September 2025 TAR showed a 03/02/2025 order to change NC every 14 days every night shift every 14 days, which was documented as done the night of 09/14/2025.A 02/26/2025 physician's order directed staff to check Sp02 every shift in a range from 90-98%.
Staff documented the sats measured every shift, but did not indicate if the resident's oxygen saturation level was measured with or without O2.During an interview on 09/24/2025 at 3:37 PM, Staff E reviewed the documentation and stated they were sure the nurses changed the tubing, and not the bottle.
Staff F stated the tasks needed to be separated into different orders.RESIDENT 9According to the 08/11/2025 Quarterly MDS Resident 9 had a diagnosis of COPD, used oxygen therapy and experienced SOB when lying flat.
Review of the 08/14/2025 COPD CP showed staff were directed to administer O2 as ordered.On 09/19/2025 at 12:29 PM Resident 9 was observed seated in a wheelchair looking out the window in their room, not wearing O2. On their wheelchair was a small 02 tank was with attached NC tubing.
Next to their bed was a 02 concentrator running at 4 lpm, without a humidified bottle.
The 02 tubing was dated 09/14/2025.On 09/24/2025 at 11:24 AM Resident 9 was observed seated in their wheelchair at bedside watching television. Resident 9 was observed wearing 02 at 4 lpm by NC with tubing dated 09/21/2025.
There was no humidified bottle on the 02 concentrator.
Review of the September 2025 TAR showed orders dated 02/10/2025 for oxygen at 2 lpm per NC routine; keep sats greater than 90% every shift.
Staff documented the orders were followed.Review of the August and September 2025 TARs showed orders dated 02/11/2025 to change humidifier bottle every 28 days every day shift, which staff documented as done 08/26/2025.
Review of the September 2025 TAR showed an order dated 02/11/2025 to change nasal canula every 14 days which was documented as done 09/09/2025.Further review of the September 2025 TAR showed a 02/16/2025 order to change oxygen tubing, concentrator bottle (if needed) and clean filter every week, every night shift, every Sunday, which was documented as done on 09/07/2025, 09/14/2025 and 09/21/2025.
During an interview on 09/24/2025 at 11:38 PM, Staff B, Director of Nursing, stated they needed to change how the orders were written.During an interview on 09/24/2025 at 11:27 AM Staff G, Licensed Practical Nurse (LPN), observed Resident 9 and the 02 setting and stated they 02 was running at 4.5 lpm, and was supposed to be at 2 lpm.During an interview on 09/24/2025 at 11:31 AM, Staff F, Resident Care Manager, stated oxygen tubing and humidifiers should be changed weekly, and residents should receive oxygen at a rate ordered by the provider.REFER TO: WAC 388-97-1060(3)(j)(vi)
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Agility Health and Rehabilitation
5520 Bridgeport Way West University Place, WA 98467
SUMMARY STATEMENT OF DEFICIENCIES
Resident 2's representative that they would call if Resident 2 refused showers.
Review of the 09/01/2025 Care Plan Report showed no behavior care planned interventions to address Resident 2's refusals of care.
During an interview on 10/03/2025 at 12:02 PM, Staff N, Social Services Director, stated they were unaware of Resident 2's refusals.
Staff N stated they would expect nursing to notify family, and for social services to be notified to explore potential reasons for the refusals, and if necessary to discuss refusals in care conferences, code the MDS and develop a plan of care.REFER TO: WAC 388-97-0960(1)
Facility ID: