B
75/100AGILITY HEALTH AND REHABILITATION Inspection Report, Violations & Safety Grade (UNIVERSITY PLACE, Washington)
5520 BRIDGEPORT WAY WEST, UNIVERSITY PLACE, Washington 98467
Phone: 2535667166
CMS Overall:3/5
Overview & Bed Count
Certified Beds
120
Avg Residents/Day
108.8
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Pierce
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall3/5
Health3/5
Staffing3/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Washington Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.65 | 0.99 | -0.34 |
| Total Nurse Hours per Resident per Day | 4.17 | 4.42 | -0.25 |
| CMS Staffing Rating | 3/5 | 3.7/5 | - |
| Nursing Staff Turnover | 38.9% | 43.9% | - |
Health Citation History
39 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-06-09 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | G – Actual Harm |
| 2026-06-09 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2026-06-09 | Environmental Deficiencies | Make sure that a working call system is available in each resident's bathroom and bathing area. | E – Moderate Harm Potential |
| 2026-06-09 | Resident Rights Deficiencies | Honor the resident's right to organize and participate in resident/family groups in the facility. | D – Moderate Harm Potential |
| 2026-06-09 | Resident Rights Deficiencies | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | D – Moderate Harm Potential |
| 2026-06-09 | Resident Rights Deficiencies | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D – Moderate Harm Potential |
| 2026-06-09 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. | D – Moderate Harm Potential |
| 2026-06-09 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2026-06-09 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2026-06-09 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2026-06-09 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D – Moderate Harm Potential |
| 2026-06-09 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2026-06-09 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2025-11-25 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | E – Moderate Harm Potential |
| 2025-11-25 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | E – Moderate Harm Potential |
| 2025-11-25 | Quality of Life and Care Deficiencies | Provide medically-related social services to help each resident achieve the highest possible quality of life. | D – Moderate Harm Potential |
| 2025-04-11 | Resident Rights Deficiencies | Honor the resident's right to organize and participate in resident/family groups in the facility. | E – Moderate Harm Potential |
| 2025-04-11 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | E – Moderate Harm Potential |
| 2025-04-11 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2025-04-11 | Resident Rights Deficiencies | Ensure that residents are fully informed and understand their health status, care and treatments. | D – Moderate Harm Potential |
| 2025-04-11 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D – Moderate Harm Potential |
| 2025-04-11 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-04-11 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-04-11 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2025-04-11 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2025-04-11 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2025-04-11 | Quality of Life and Care Deficiencies | Provide routine and 24-hour emergency dental care for each resident. | D – Moderate Harm Potential |
| 2025-04-11 | Quality of Life and Care Deficiencies | Provide or obtain dental services for each resident. | D – Moderate Harm Potential |
| 2025-04-11 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | D – Moderate Harm Potential |
| 2025-04-11 | Nursing and Physician Services Deficiencies | Post nurse staffing information every day. | C – Minimal Harm Potential |
| 2024-05-09 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | E – Moderate Harm Potential |
| 2024-05-09 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2024-05-09 | Resident Rights Deficiencies | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | D – Moderate Harm Potential |
| 2024-05-09 | Resident Assessment and Care Planning Deficiencies | PASARR screening for Mental disorders or Intellectual Disabilities | D – Moderate Harm Potential |
| 2024-05-09 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2024-05-09 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2024-05-09 | Quality of Life and Care Deficiencies | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | D – Moderate Harm Potential |
| 2024-05-09 | Quality of Life and Care Deficiencies | Provide or obtain dental services for each resident. | D – Moderate Harm Potential |
| 2023-11-21 | Infection Control Deficiencies | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | E – Moderate Harm Potential |
Fire Safety Citation History
21 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-06-09 | Emergency Preparedness Deficiencies | List the names and contact information of those in the facility. | F – Moderate Harm Potential |
| 2026-06-09 | Egress Deficiencies | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | F – Moderate Harm Potential |
| 2026-06-09 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2026-06-09 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | E – Moderate Harm Potential |
| 2026-06-09 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2026-06-09 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2026-06-09 | Miscellaneous Deficiencies | Have restrictions on the use of highly flammable decorations. | D – Moderate Harm Potential |
| 2026-06-09 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2025-04-11 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | F – Moderate Harm Potential |
| 2025-04-11 | Emergency Preparedness Deficiencies | Establish procedures for tracking staff and patients during an emergency. | F – Moderate Harm Potential |
| 2025-04-11 | Emergency Preparedness Deficiencies | Establish staff and initial training requirements. | F – Moderate Harm Potential |
| 2025-04-11 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-04-11 | Construction Deficiencies | Meet other general requirements. | D – Moderate Harm Potential |
| 2024-05-09 | Emergency Preparedness Deficiencies | Establish staff and initial training requirements. | F – Moderate Harm Potential |
| 2024-05-09 | Smoke Deficiencies | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | F – Moderate Harm Potential |
| 2024-05-09 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | F – Moderate Harm Potential |
| 2024-05-09 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2024-05-09 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2024-05-09 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2024-05-09 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2024-05-09 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D – Moderate Harm Potential |
Total Penalties & Fines
$16,350
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-06-09 | Fine | $16,350 | - |
Need Help Finding Safe Care?
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the UNIVERSITY PLACE area at no cost.
Find Safe, Vetted Facilities Near UNIVERSITY PLACE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.