Linden Grove Health Care: Care Plan Failures - WA
Federal inspectors returned to Linden Grove Health Care Center on January 29 and found, again, that the facility had failed to hold timely care planning meetings with residents or their responsible parties. Two of the four residents whose records inspectors reviewed had not received meetings on schedule.
The same deficiency was documented in November 2018. Then again in November 2019. Then again in January 2024. Now January 2025.
That is four inspection cycles. Four citations. The same failure, written up the same way, involving the same basic obligation: sit down with a resident, or the family member who speaks for them, and talk through their care.
Care planning meetings are not a bureaucratic formality. They are the mechanism by which residents and families learn what is happening — what goals staff are working toward, what has changed, what the plan is if something goes wrong. When those meetings don't happen on time, residents go without a voice in decisions being made about their own bodies.
At 1:34 in the afternoon on the day of the inspection, a staff member identified in the report only as Staff A told inspectors that the facility's Quality Assurance and Performance Improvement committee, known as QAPI, was not aware of the concerns in this area.
That sentence deserves to sit alone for a moment.
The QAPI committee exists specifically to identify problems like this one and fix them before federal inspectors have to come back and write them down again. If the committee responsible for quality oversight did not know that care planning meetings were being missed, it means the internal system for catching failures was not catching this failure, despite it appearing on federal inspection records in 2018, 2019, 2024, and now 2025.
The violation was cited at scope and severity level D, meaning inspectors determined it caused minimal harm or had the potential to cause more than minimal harm to a limited number of residents. The 2024 citation carried a level E, meaning inspectors found the same pattern affecting a larger group. This year's citation returned to D. The letter changes. The underlying problem does not.
What this means in practice is that somewhere inside Linden Grove, at least two residents went through a period in which their care plan meeting came and went without them, or without whoever is supposed to speak for them. No one sat across a table from them, or from their daughter, or their son, or their designated representative, and walked through the plan. The window passed.
For a resident who is alert and able to advocate for themselves, a missed meeting is a frustration and a loss of information. For a resident with dementia, or one who cannot communicate easily, or one whose family lives far away and counts on these scheduled touchpoints to understand what is happening, a missed meeting can mean weeks of decisions made in a vacuum.
Linden Grove has not been cited for this violation once and corrected it. The facility has been cited, submitted a correction plan, passed subsequent inspections on this point for a period, and then been cited again. The 2019 citation came a year after the 2018 citation. The 2024 citation came more than four years after that. The 2025 citation came twelve months after the 2024 citation.
The staff member who spoke to inspectors on January 29 did not describe a facility that had tried to fix the problem and failed in some complicated way. They described a quality committee that did not know the problem existed.
Six years of federal inspection records say otherwise.
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 8, 2026 · Our methodology
LINDEN GROVE HEALTH CARE CENTER in PUYALLUP, WA was cited for violations during a health inspection on January 29, 2025.
Two of the four residents whose records inspectors reviewed had not received meetings on schedule.
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.