Agility Health And Rehabilitation

Findings included . Resident 112 Observation on 06/03/2026 at 10:16 AM and 06/06/2026 at 9:20 AM showed Resident 112's room had a single crack in the right windowpane extending the length of the window.

During an interview on 06/09/2026 at 10:55 AM, Staff Q, Maintenance Director, stated the window had been broken for six months, they did not have the authority to purchase a replacement window, and facility administration was aware of the crack.

During an interview on 06/09/2026 at 10:16 AM, Staff A, Administrator, stated they were unaware the window was cracked.

Staff A stated the maintenance department conducted several monthly resident room audits and the window should have been noted and repaired.

Staff A stated the cracked resident window did not reflect a homelike environment. Resident 67 Review of the electronic health record (EHR) showed Resident 67 admitted to the facility on [DATE] with a diagnosis of diabetes (when the body cannot process sugars) and the resident was able to make needs known.

During an interview and observation on 06/03/2026 at 9:25 AM, Resident 67 stated Housekeeping does not sweep and mop, and they just finished cleaning their room but left the floors dirty.

There was trash and a liquid spilled on the floor between the beds.

During an interview and observation on 06/04/2026 at 11:31 AM, Resident 67 stated staff had still not swept or mopped, and the trash and spill was still observed on the floor between the beds.

Review of the resident council notes for the month of March 2026 showed a resident request for housekeeping to ensure beds, nightstands and surrounding areas were cleaned thoroughly.

Review of resident council notes for the month of April 2026 showed reported concerns for housekeeping not removing trash from under the bed for three days.

During an interview on 06/09/2026 at 9:40 AM, Staff K, Housekeeping, stated the rooms should be swept and mopped every day.

During an interview on 06/09/2026 at 9:59 AM, Staff A, Administrator, stated it was their expectation that the resident rooms be swept and mopped daily and as needed.

Reference WAC 388-97-0880, -2040 .

505473 06/09/2026

Agility Health and Rehabilitation 5520 Bridgeport Way West University Place, WA 98467

Findings included.

Review of the electronic health record showed Resident 138 admitted to the facility on [DATE] with diagnoses to include pneumonia (a lung infection causing inflammation), chronic kidney disease, and diabetes (too much sugar in the blood). Resident 138 was able to make needs known.

Observation and interview on 06/05/2026 at 12:02 AM showed Resident 138 sat in their wheelchair just inside their room door with an upset expression. Resident 138 stated they had turned on their call light because they needed assistance to use the restroom. Resident 138 stated a staff had entered their room, turned off their call light, and stated they would return to assist Resident 138. Resident 138 stated they had been waiting for fifteen to twenty minutes for the staff to return, and they were pissed they had to wait to use the restroom.

Observation on 06/05/2026 at 12:28 PM showed Resident 138's concern regarding staff turning off their call light without assisting them was reported to Staff S, Licensed Practical Nurse.

During an interview on 06/09/2026 at 10:03 AM, Staff A, Administrator, stated if a resident made a report that staff had turned off their call light without providing care, a grievance should be completed for the concern.

Staff A stated turning off the call light without providing care increased the likelihood of neglect occurring if the staff member forgot to return.

Staff A stated no grievance or investigation was initiated in response to Resident 138's concern, and this did not meet expectations.

Reference WAC 388-97-0460

505473 06/09/2026

Agility Health and Rehabilitation 5520 Bridgeport Way West University Place, WA 98467

Findings included.

Review of the facility policy titled Use of Psychotropic Medication, revised 04/23/2025, showed Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication and Pre-admission screening [PASRR, a mental health screening tool] and other pre-admission data shall be utilized for determining indications for use of medications ordered upon admission to the facility.

Review of the electronic health record (EHR) showed Resident 50 admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that effects memory) with behaviors, and depression.

The resident was sometimes able to make needs known.

Review of the facility initiated PASRR form dated 03/27/2026 showed Resident 50 had a diagnosis of depression and anxiety.

Review of an updated PASRR form dated 04/06/2026 showed Resident 50 had a diagnosis of severe depression.

Review of the provider orders showed Resident 50 was prescribed Risperidone (an antipsychotic medication) daily at bedtime for dementia with behaviors with a start date of 03/31/2026.

Review of the EHR showed no order to monitor target behaviors related to the antipsychotic medication.

Review of the EHR on 06/05/2026 showed no documentation that Resident 50 was reviewed on admission for the use of an antipsychotic medication.

During an interview on 06/05/2026 at 10:56 AM, Staff N, Licensed Practical Nurse, stated Resident 50's diagnosis of dementia with behaviors was not an appropriate diagnosis for an antipsychotic medication and the resident should have a monitor for target behaviors for the antipsychotic in place but did not.

During an interview on 06/05/2026 at 11:01 AM, Staff P, Social Services Director, stated Resident 50 should have been reviewed in the monthly psychotropic meeting on admission.

Staff P stated dementia with behaviors was not an appropriate diagnosis for the use or Risperidone and related behaviors should have been monitored.

Staff P stated Resident 50 did not display aggressive or violent behaviors; they just wandered frequently.

During an interview on 06/05/2026 at 11:56 AM, Staff B, Director of Nursing Services, stated it was their expectation that Resident 50 should have been reviewed in the monthly psychotropic meeting, had target behaviors monitored and an appropriate diagnosis for the use of an antipsychotic.

Reference WAC 388-97-1060(3)(k)(i), -0620(1)(a)

505473 06/09/2026

Agility Health and Rehabilitation 5520 Bridgeport Way West University Place, WA 98467

During a joint interview on 06/04/2026 at 3:05 PM, Resident 7 stated the incident happened here at the facility.

Collateral Contact AA stated Resident 7 had told them about the incident just prior to reporting it to the speech therapist.

During a joint interview on 06/04/2026 at 3:15 PM, Staff A, Administrator (ADM), and Staff B, Director of Nursing Services (DNS), stated it was their expectation that this be reported and investigated and this did not meet their expectations.

Reference WAC 388-97-0640(5)(a)

505473 06/09/2026

Agility Health and Rehabilitation 5520 Bridgeport Way West University Place, WA 98467

Findings included . Resident 112 Review of the electronic health record (EHR) showed Resident 112 admitted to the facility on [DATE] with diagnoses that included diabetes (uncontrolled blood sugar), weakness, and hemiplegia and hemiparesis affecting right side (partial loss of strength and near complete loss of voluntary movement). Resident 112 was able to make needs known.

Review of the EHR showed Resident 112 weighed184 pounds on 03/14/2026, 150 pounds on 04/11/2026 and 146 pounds on 04/19/2026.

Review of Section K (Swallowing/Nutritional status) on the 05/06/2026 quarterly MDS showed Loss of 5 percent or more in the last month or loss of 10 percent or more in last 6 months marked NO or UNKOWN.

During an interview on 06/08/2026 at 9:41 AM, Staff G, MDS/Licensed Practical Nurse (MDS/LPN), stated the dietician completed that part of the MDS; however, it should have reflected significant weight loss and been marked YES During an interview on 06/06/2026 at 2:56 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was that MDS assessments were coded accurately. Resident 21 Review of the EHR showed Resident 21 was admitted to the facility on [DATE] with diagnoses to include malignant neoplasm (cancer) of lung, secondary malignant neoplasm of brain and adrenal gland (small gland that produces hormones).

Review of admission MDS dated [DATE] showed Resident 21 was able to communicate needs and did not have cancer diagnoses in section I for active diagnoses.

During an interview on 06/05/2026 at 12:01 PM, Staff G, MDS/LPN, stated the cancer diagnosis was missing from the MDS and it should have been coded.

During an interview on 06/09/2026 at 9:41 AM, Staff B, DNS, stated the expectation was for active diagnoses to be on the MDS.

Reference WAC 388-97-1000(1)(a)(b)(4)(a)

505473 06/09/2026

Agility Health and Rehabilitation 5520 Bridgeport Way West University Place, WA 98467

Review of the care plan created on 03/01/2026 showed Resident 98 had no problem, goal or

During an interview on 06/08/2026 at 1:32 PM, Staff H, Registered Nurse, stated visual deficits should be addressed in the care plan.

During an interview on 06/09/2026 at 9:43 AM, Staff B, DNS, stated the lack of visual deficit on the care plan for Resident 98 did not meet expectations.

Reference WAC 388-97-1020(1)(2)(a)(b)

505473 06/09/2026

Agility Health and Rehabilitation 5520 Bridgeport Way West University Place, WA 98467

Review of a provider note dated 06/02/2026 showed [Resident 81] stated has had 3 days of diarrhea with abdominal discomfort, Loperamide [medication to treat loose stools] was started as needed [PRN] for diarrhea management. If Loperamide did not aid in symptom relief, symptoms persist for more than 3 days to notify the provider.

Review of the bowel monitor showed Resident 81 had two loose stools on 06/04/2026, three large loose stools on 06/05/2026 and two large loose stools on 06/06/2026, 06/07/2026 and 06/08/2026.

During an interview on 06/05/2026 at 8:55 AM, Resident 81 stated it happens all the time. If they moved, they had wet stool. Resident 81 stated staff had not given them any medication for it.

Review of the June 2026 medication administration record (MAR) showed no doses of Loperamide were documented as administered.

Review of the EHR showed no documentation that the provider was notified of the three large loose stools on 06/05/2025.

During an interview on 06/05/2026 at 8:54 AM, Staff M, Registered Nurse (RN), stated if a resident was having frequent loose stools they should report to the provider and give any PRN medications.

During an interview on 06/05/2026 at 10:51 AM, Staff N, Licensed Practical Nurse (LPN), stated if a resident was having more than three loose stools in 24 hours the staff should have notified the provider and given any PRN medications and placed them on alert charting.

During an interview on 06/05/2026 at 12:08 PM, Staff B, Director of Nursing Services (DNS), stated it was their expectation that staff notify the provider, place the resident on alert, test for infection if indicated and give any PRN medications.

This did not happen for Resident 81 and should have. <Anticoagulant>

Review of the EHR showed Resident 81 was receiving anticoagulant (blood thinning) injections daily with a start date of 05/21/2026.

During an interview and observation on 06/03/2026, Resident 81 laid in bed with an indwelling urinary catheter (a tube used to drain urine from the bladder).

There was dark red urine noted in the tube/bag.

Resident 81stated It's never been like that. It's scary.

Review of the EHR on 06/05/2026 showed no monitoring for bleeding and bruising related to being on anticoagulant therapy.

Review of the progress notes on 06/05/2026 showed no documentation related to the blood in the urine and no alert charting.

During an interview on 06/05/2026 at 10:39 AM, Staff O, Certified Nursing Assistant (CNA), stated Resident 81 had the blood in their catheter for a couple days.

During an interview on 06/05/2026 at 10:42 AM, Staff M, RN, stated if Resident 81 was on an anticoagulant they should be monitored for bleeding and bruising.

During an interview on 06/05/2026 at 10:44 AM, Staff N, LPN, stated Resident 81 should have had a monitor for bleeding order but did not and should have been placed on alert for bleeding but was not.

During an interview on 06/05/2026 at 11:58 AM, Staff B, DNS, stated Resident 81 should have had an anticoagulant side effect monitor in place and should have been placed on alert for bleeding and this did not happen.

Reference WAC 388-97-1060(1)-(3)

505473 06/09/2026

Agility Health and Rehabilitation 5520 Bridgeport Way West University Place, WA 98467

Findings included .Resident 24

Review of the electronic health record (EHR) showed Resident 24 admitted to the facility on [DATE] with diagnoses that included ankylosis of left knee (stiffness and immobility of a joint), diabetes (uncontrolled blood sugar), and generalized muscle weakness. Resident 24 was able to make needs known.

During an interview on 06/04/2026 at 9:20 AM, Resident 24 stated they were told they would be starting an exercise program after discharge from physical therapy. Resident 24 stated they had not been offered participation in a restorative program.

Review of Resident 24's Physical Therapy Discharge summary dated [DATE] showed Discharge Recommendations: Restorative Range of Motion Program (bilateral lower extremity).

Review of Resident 24's care plan initiated 12/25/2025 showed no Restorative program intervention.

During an interview on 06/05/2026 at 12:48 PM, Staff D, Director of Rehabilitation (DOR), stated the facility failed to initiate and implement a restorative program for Resident 24 after discharge from physical therapy.

Resident 112Review of EHR showed Resident 112 admitted to the facility on [DATE] with diagnoses that included diabetes, weakness, and hemiplegia and hemiparesis affecting right side (partial loss of strength and near complete loss of voluntary movement). Resident 112 was able to make needs known.

Observations on 06/03/2026 at 1:25 PM and 06/04/2026 at 9:33 AM showed an elbow splint on a corner table in Resident 112's room.

Review of the EHR showed an order to Apply right elbow extension splint on in AM for up to six hours per day, as tolerated three to six times per week.

Review of a 06/04/2026 progress note showed, Discontinued restorative program and splinting per recommendations related to resident refusing.

Updated care plan, tasks and restorative aid.

Review of the restorative flow sheet from 05/14/2026 to 06/04/2026 showed Resident 112 refused splint assistance on three occasions.

Documentation showed Resident 112 was re-approached by alternate staff and was agreeable to wear the splint.

During an interview on 06/05/2026 at 11:16 AM, Staff Y, Restorative Aide, stated they did not have any experience with Resident 112 refusing splint assistance.

Staff Y stated the best approach with Resident 112 was to explain that the splint would not be painful.

During an interview on 06/05/2026 at 12:27 PM, Staff D, DOR, stated it was uncommon for three refusals in 30 days to warrant discontinuation of a restorative program.

Staff D stated it did not meet expectations that the program was discontinued for three refusals.

Reference WAC 388-97-1060(3)(d)

505473 06/09/2026

Agility Health and Rehabilitation 5520 Bridgeport Way West University Place, WA 98467

During an interview on 06/05/2026 at 12:07 PM, Staff B, DNS, Stated Resident 50 was not referred to therapy but it was discussed in clinical meeting.

Staff B stated Resident 50 should have had their orthostatic blood pressures taken accurately to rule out orthostatic hypotension.

Reference WAC 388-97-1060(3)(g)

505473 06/09/2026

Agility Health and Rehabilitation 5520 Bridgeport Way West University Place, WA 98467

Review of the EHR showed Resident 112 weighed 184 pounds on 03/14/2026, 150 pounds on 04/11/2026 and 146 pounds on 04/19/2026, a 20 percent loss in total body weight.

Review of Resident 112's 02/10/2026 care plan showed staff were to monitor meal intake and offer meal replacement if Resident 112 ate less than 50 percent.

Review of Resident 112's nutritional intake task documentation for March 2026 showed Resident 112 had less than 50 percent intake for one or more meals 26 out of 31 days.

Review of Resident 112's nutritional intake task documentation for April 2026 showed Resident 112 had less than 50 percent intake for one or more meals 15 out of 30 days.

Review of the nutritional intake task documentation from 05/14/2026 to 06/09/2026 showed Resident 112 had less than 50 percent intake for one or more meals for the 28 days.

The EHR showed no documentation that staff offered Resident 112 meal replacement during March, April, May or June 2026.

Review of the Kardex (Care Plan directive for staff) showed no intervention to offer Resident 112 a meal replacement.

Review of a Dietary/Nutrition progress note dated 04/21/2026 showed, Resident is triggering for significant weight loss, will discuss feeding tube related to poor nutritional intake at 4/29/2026 care conference.

Review of the quarterly Interdisciplinary Team care conference document dated 04/29/2026 showed Resident 112's dietary/nutrition status showed the following documentation, IDT reviewed with no concerns, changes, or questions at this time.

Reivew did not show a feeding tube or other weigh loss strategies were implemented.

Review of a Nutritional Assessment completed 05/07/2026 showed, Accounting for weight loss from 4/11/26 - 4/19/26 (not significant); suspect weight precision masked true weight loss as resident's clothes appeared to fit more loosely than on admit and mild-moderate wasting observed in temples and orbitals.

Diagnosis- unintentional weight loss, swallowing difficulty and self-feeding difficulty.

Continue regular diet; add fortified foods, large protein, evening snack and assistance with meals.

During an interview on 06/05/2026 at 3:04 PM, Staff X, Regional Dietician, stated weight reports were pulled weekly and addressed by nursing staff and the Dietician on Tuesdays.

Staff X stated based on Resident 112's documented weights in the EHR, the weight loss should have been addressed sooner than the 05/07/2026 progress note.

Staff X stated the Certified Nursing Assistants (CNA) should have offered meal replacement and maybe they did but the facility did not have a place for the CNA to document if meal replacement was offered and accepted.

Reference WAC 388-97-1060 (3)(h) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

505473 06/09/2026

Agility Health and Rehabilitation 5520 Bridgeport Way West University Place, WA 98467

Findings included .

Review of the provider's orders for June 2026 showed Resident 96 was prescribed nine oral medications with a specific time of administration to be given at 8:00 AM.

Observation of medication administration on 06/08/2026 at 9:36 AM showed Staff J, Licensed Practical Nurse (LPN), prepared and administered these nine oral medications to Resident 96 (one hour and 36 minutes late).

During an interview on 06/08/2026 at 10:13 AM, Staff J, LPN, stated the nurses had up to two hours to administer medications after the ordered time.

During an interview on 06/08/2026 at 10:17 AM, Staff B, Director of Nursing Services, stated the medication administration time was one hour before and one hour after the specific time of the order, and the expectation was for nurses to follow orders including the correct time of administration and this did not meet expectations.

Reference WAC 388-97-1060(3)(k)(ii)

During an interview on 06/09/2026 at 10:39 AM, when asked to look at the emergency call light pull cords in rooms 106, 107, 121, and 311, Staff Q, Maintenance Director, asked how long the pull cord had to be and stated they were unaware of any regulation related to bathroom call light pull cords.

During an interview on 06/09/2026 at 11:09 AM, Staff A, Administrator, stated the expectation was that resident bathroom pull cords should be accessible to call for help if the resident was on the floor.

Reference WAC 388-97-2280 (1)(a)

505473 06/09/2026

Agility Health and Rehabilitation 5520 Bridgeport Way West University Place, WA 98467