Linden Grove Health Care: Restraint Violations - WA
Nobody on the facility's quality committee knew it was happening.
Low beds, which sit closer to the floor than standard hospital beds, are classified as a physical restraint under federal nursing home rules. They restrict a resident's ability to move freely and must be ordered by a physician, supported by a clinical assessment, and accepted by the resident or their representative before they can be used. At Linden Grove, inspectors found that none of those steps had been completed for any of the three residents they reviewed.
The finding wasn't a surprise to federal regulators. They had cited Linden Grove for the same violation less than two months earlier, on December 5, 2024.
When inspectors returned in January, the problem remained. All three of the residents sampled during the survey were in low beds without the required documentation. The inspection report does not describe the residents by name, age, or diagnosis, only that there were three of them and that in each case the facility had failed to obtain what was needed before restricting their movement.
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, the internal body responsible for identifying and correcting care problems, was not aware of the concerns in this area.
That admission sits at the center of what makes this finding more than a paperwork problem. A facility's QAPI process is its own mechanism for catching exactly this kind of failure before federal inspectors have to. If the committee responsible for quality oversight had no knowledge that residents were being placed in restraints without orders or consent, the question isn't only whether the right forms were filled out. The question is whether anyone inside the building was watching.
The same deficiency category, F604, had been cited at the D level in December, meaning inspectors determined it caused or had the potential to cause minimal harm to a limited number of residents. The January citation carries the same severity level. That the violation persisted at the same level after a prior citation suggests the facility did not implement a correction that held.
Physical restraints in nursing homes carry well-documented risks. Residents placed in restraints without proper assessment may be at greater risk of injury, particularly if the clinical justification for the restraint was never evaluated. Consent requirements exist because residents retain the right to refuse interventions that limit their freedom of movement, even when those interventions are framed as safety measures.
Linden Grove Health Care Center is a long-term care facility in Puyallup, a city in Pierce County south of Tacoma. The inspection report does not name the residents affected, does not describe their medical conditions, and does not indicate whether any of them or their families were ever told that a low bed qualified as a restraint requiring their agreement.
What the report does say is that when a federal inspector asked about it on a Wednesday afternoon in late January, the staff member present confirmed that the people charged with overseeing the facility's own quality had not flagged the issue at all.
The three residents in those beds may not have known their consent was supposed to be asked for. According to the inspection record, the facility's quality committee didn't know either.
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.
Nobody on the facility's quality committee knew it was happening.
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.