Linden Grove Health Care: Care Plan Failures - WA
Federal inspectors cited Linden Grove Health Care Center on January 29, 2025 for failing to develop and implement comprehensive, person-centered care plans for two of the 24 residents they reviewed. It was not the first time inspectors had found this problem at Linden Grove. It was the third.
The same violation was documented in November 2019. Then again in October 2022. Now 2025.
A care plan is not a formality. For a nursing home resident, it is the document that tells every nurse, every aide, and every therapist who walks through the door what that person needs, what their goals are, and how the facility intends to meet them. Without one, or with one that is incomplete or unimplemented, care becomes improvised. The people providing it are working without a map.
For two residents at Linden Grove, that map was missing.
When inspectors spoke with Staff A at 1:34 in the afternoon on the day of the inspection, the answer they received said as much about the facility's internal systems as it did about the two residents whose care plans were deficient. Staff A told inspectors that the facility's QAPI committee, the Quality Assurance and Performance Improvement body that exists specifically to identify and correct problems like this one, was not aware of the concerns in this area.
Not aware. In 2025. After 2022. After 2019.
QAPI committees are how nursing homes are supposed to catch their own failures before a federal inspector has to. The committee reviews data, tracks patterns, and is meant to surface exactly the kind of recurring problem that Linden Grove has now had documented three times. If the committee responsible for quality oversight did not know that care planning was a problem, the question is not just why two residents lacked adequate care plans. The question is what the committee has been reviewing, and whether anyone connected the 2022 citation to the work that was supposed to follow it.
The deficiency is classified at scope and severity level D, meaning inspectors determined it caused no actual harm but had the potential to affect more than an isolated number of residents. That classification carries its own weight here. The same level D finding in 2019, and again in 2022, did not prevent a third.
There is a version of this story where a facility gets cited, corrects the problem, and the violation does not reappear. Linden Grove has not been that facility. What the record shows instead is a deficiency that was identified, presumably addressed, closed out, and then found again two years later, and then found again two and a half years after that.
The two residents whose care plans were flagged in January are not named in the inspection report. What they experienced in the gap between what their care plans required and what the facility had actually developed for them is not detailed. The inspection narrative does not say whether they experienced harm as a result. What it says is that the plans were not there, or were not adequate, and that the body charged with making sure that does not happen did not know it was happening.
Linden Grove has 130 certified beds and serves both long-term residents and those in short-term rehabilitation. The facility is owned and operated within a regional network. None of that context changes what the inspection record shows: a pattern of the same failure, documented across three separate surveys, with a quality committee that, as of the afternoon of January 29, 2025, had not been tracking it.
The residents whose care plans were missing are still there.
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.
It was not the first time inspectors had found this problem at Linden Grove.
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.