Linden Grove Health Care Center: Drug Review Failures - WA
The January 29 inspection found that Linden Grove failed to act on a consultant pharmacist's medication regimen review recommendations for one of five residents whose records were examined. There was no documented response. No rationale explaining why the recommendation was set aside. Just silence in the record where an answer was supposed to be.
That alone would be a significant finding. What makes it harder to dismiss is that federal inspectors cited Linden Grove for the exact same violation in November 2018.
Six years passed between those two citations. The violation carries a severity tag of "D," meaning inspectors determined it caused, or had the potential to cause, actual harm to at least one resident. It is not a paperwork technicality. Medication regimen reviews exist because drug combinations in elderly patients can cause falls, internal bleeding, sedation, and death. The pharmacist's job is to catch what daily clinical routines might miss. When a facility ignores what the pharmacist found, whatever risk the pharmacist identified stays in place.
The inspection report does not name the resident whose medications were flagged, and it does not describe what the pharmacist recommended or why the staff failed to respond. Five residents were sampled. One had a recommendation sitting unanswered. The other four did not.
That ratio matters. This is not a facility where the process has completely broken down across the board. It is a facility where, at least in one case, the process produced a finding and then stopped. Someone reviewed the medications, identified something worth flagging, wrote it up, and sent it forward. Then nothing happened on the other end. No action. No documented disagreement. No follow-through.
Facilities are not required to do everything a consultant pharmacist recommends. Physicians can review a recommendation and decide the current regimen is appropriate for a specific patient's condition. That clinical judgment is legitimate. But it has to be written down. The regulation exists precisely because "we considered it" is not a verifiable statement without documentation. If there is no record, there is no accountability, and there is no way for the next pharmacist, the next physician, or the next inspector to know what decision was made and why.
Linden Grove did not provide that record.
The 2018 citation did not appear to produce a lasting correction. Whatever steps the facility took after that inspection, they did not prevent the same gap from appearing again when inspectors returned in January 2025. That is the detail that sits at the center of this finding: not just that a recommendation went unaddressed, but that this has happened before, that the facility has been told before, and that the problem was still present when inspectors looked again.
Medication management in long-term care settings is genuinely difficult. Residents often take a dozen or more drugs simultaneously. Conditions change. Prescriptions accumulate over years of treatment by different physicians. The consultant pharmacist review is designed as an independent check on that complexity, a set of outside eyes that reviews the full picture on a regular schedule. When that check produces a recommendation and the recommendation disappears into the facility without a trace, the check did not function.
For the resident whose medications were flagged in January 2025, whatever the pharmacist believed warranted attention remained unresolved, at least as of the inspection date. The report does not say whether the resident experienced any adverse effects. It does not say whether the recommendation was eventually acted upon after inspectors arrived. It records only what was found: a recommendation made, and no documented response to it.
That resident's name does not appear in the report. What the pharmacist was worried about does not appear either. The inspection record shows a gap where an answer should have been, and a nearly identical gap that was documented at the same facility six years before.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Linden Grove Health Care Center from 2025-01-29 including all violations, facility responses, and corrective action plans.
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: August 9, 2026 · Our methodology
LINDEN GROVE HEALTH CARE CENTER in PUYALLUP, WA was cited for violations during a health inspection on January 29, 2025.
There was no documented response.
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.