Linden Grove Health Care Center: Pressure Ulcer Failures - WA
Federal inspectors who visited the facility on January 29, 2025 found that Linden Grove had failed to monitor and use low air loss mattresses as directed for three of the seven residents whose records they reviewed. The mattresses, which redistribute pressure evenly across a patient's body, are prescribed specifically for people whose condition puts them at serious risk of developing pressure ulcers.
Pressure ulcers, commonly called bedsores, are not a minor inconvenience. They begin when sustained pressure cuts off blood flow to skin and underlying tissue, typically at bony points like the heels, hips, and tailbone. Left unaddressed, they can progress from reddened skin to open wounds that reach muscle and bone, creating pathways for infection that can turn fatal. For nursing home residents, who are often immobile, incontinent, and medically fragile, the risk is constant and the consequences can be severe.
The low air loss mattress is one of the more direct tools a care team can deploy against that risk. It works by continuously circulating air through chambers to reduce the pressure any one point of the body sustains over time. When a physician or wound care specialist orders one, it reflects a clinical judgment that the resident's condition warrants that level of intervention. Failing to use it, or failing to confirm it is functioning and positioned correctly, means the protection the doctor ordered simply does not exist.
That is what inspectors documented at Linden Grove for three residents.
The inspection report does not describe what stage those residents' skin was in when the failure was discovered, or whether any of them had developed wounds by the time inspectors arrived. What it does establish is that the facility had identified these individuals as needing this specific intervention, had a directive in place, and then failed to ensure the directive was carried out or checked.
Three out of seven is not a rounding error. It is nearly half the residents whose records inspectors pulled for this review.
Linden Grove Health Care Center is a long-term care facility in Puyallup, south of Tacoma. The January inspection was a standard health survey. The pressure ulcer finding was cited at scope and severity level E, meaning inspectors determined it affected more than an isolated number of residents but had not yet caused serious harm, or harm they could document at the time of the visit.
That designation, "not yet causing serious harm," is worth sitting with. Pressure ulcers do not announce themselves. A resident lying on a mattress that is not functioning as ordered, or that staff have not confirmed is properly set up, may not show visible skin breakdown for days. By the time a wound is visible, the tissue damage underneath has often been progressing for longer than the surface suggests.
The residents at the center of this finding were people whose doctors had already looked at their condition and concluded that without a specific kind of mattress, they were at meaningful risk. The facility's job, at that point, was to make sure the mattress was there, working, and being checked. Inspectors found it was not.
Whether any of those three residents developed pressure ulcers as a result is not something the inspection report resolves. What it records is the gap between what was ordered for them and what was actually verified on their behalf, measured in the number of times staff confirmed the intervention was in place and functioning.
For residents who cannot reposition themselves, cannot check whether the equipment beneath them is working, and cannot report what they cannot feel, that gap is not abstract.
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.
Pressure ulcers, commonly called bedsores, are not a minor inconvenience.
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.