Linden Grove Health Care: Mental Health Screen Failures - WA
Federal inspectors cited Linden Grove for failing to complete Pre-Admission Screening and Resident Review assessments, known as PASARR, for two of the seven residents whose records they examined. PASARR is the mental health screening process used to determine whether a person entering a long-term care facility has a serious mental illness or intellectual disability that would require specialized services. The screenings are supposed to happen before a resident is admitted, or within defined timeframes after a change in condition.
At 1:34 in the afternoon on the day of the inspection, a staff member identified in the report only as Staff A confirmed to inspectors that the facility's QAPI committee, the internal body charged with tracking and improving care quality, was unaware of the concerns in this area.
The same deficiency had been cited at Linden Grove on January 26, 2024.
That gap matters. A year passed between the first citation and the second. The facility's own quality oversight process, the mechanism that exists specifically to catch recurring problems before federal inspectors do, had not flagged it. When inspectors returned and found the same failure, the person they spoke to couldn't point to any internal awareness that the issue remained unresolved.
PASARR failures don't always generate headlines. The screening process is bureaucratic by nature, a series of forms and timelines that can seem distant from the daily reality of resident care. But the screenings exist because Congress determined, decades ago, that nursing homes were being used to warehouse people with serious mental illness who needed a different level of care, and that residents with unidentified mental health needs were going without services that could meaningfully improve their lives.
When a PASARR assessment is missing or inaccurate, the resident's care plan may be built on an incomplete picture. Specialized psychiatric services, behavioral support, or other interventions that a resident qualifies for may never be arranged. The harm isn't always visible in the way a fall or a pressure wound is visible. But it is harm.
Inspectors rated the violation at severity level D, meaning minimal harm or potential for actual harm, with some residents affected. It is the same severity level assigned to the 2024 citation.
What the inspection record shows, across two consecutive annual surveys, is a facility that identified or was told about a compliance gap in its mental health screening process and did not fix it, or did not fix it in a way that held. And when inspectors came back and asked about it, the answer from quality staff was not that the problem had been addressed and slipped through again. The answer was that the committee hadn't known.
Two residents out of seven sampled had assessments that were either inaccurate or not completed on time. The report does not describe what was missed in their screenings, what conditions or histories went unexamined, or whether the gap affected the services they received. Those details are not in the public record.
What is in the record is a facility that received the same citation in back-to-back years and a quality committee that, as of the afternoon of January 29, 2025, had not been looped in.
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.
The screenings are supposed to happen before a resident is admitted, or within defined timeframes after a change in condition.
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.