Agility Health And Rehabilitation
Inspection Findings
F-Tag F0610
F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
blind. 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)
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Agility Health and Rehabilitation
5520 Bridgeport Way West University Place, WA 98467
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0695
F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
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)
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/25/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Agility Health and Rehabilitation
5520 Bridgeport Way West University Place, WA 98467
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0745
F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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)
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Facility ID:
If continuation sheet
AGILITY HEALTH AND REHABILITATION in UNIVERSITY PLACE, WA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in UNIVERSITY PLACE, WA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AGILITY HEALTH AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.