Linden Grove Health Care: Narcotic Diversion Violations - WA
Federal inspectors rated the violation Immediate Jeopardy, the most serious classification available under Medicare's inspection system, meaning the pattern of errors posed a risk of serious harm or death to residents.
The discrepancies stretched across at least four residents and nearly six weeks.
Resident 5 alone had 21 undocumented doses. Between July 22 and August 3, the narcotic log showed that person received clonazepam eight times and oxycodone thirteen times, at hours ranging from 4:00 AM to 10:00 PM. None of those administrations appeared in Resident 5's electronic medication record.
Resident 6 had two undocumented doses of oxycodone on consecutive overnight shifts, July 31 at 6:00 PM and August 1 at 2:00 AM. Resident 4 received a dose of lorazepam on August 2 at 11:02 PM that was never entered into their record either.
The facility's Director of Nursing Services, identified in the inspection report only as Staff A, told inspectors on August 14 what happened when the nurse at the center of the investigation, identified as Staff B, was asked to explain an extra dose of morphine signed out from a fourth patient's narcotic log. Staff B's answer, according to the Director of Nursing: "I don't know."
That was enough. The Director of Nursing said the facility terminated Staff B's employment based on the investigation's findings and what inspectors described as a pattern of incorrect narcotic administration documentation.
What the inspection report does not say is whether any resident was harmed, whether any of the drugs were actually administered to the patients listed in the narcotic log, or whether they went somewhere else. That gap is the nature of diversion investigations. When a controlled substance disappears from a log without a corresponding record of who received it, or when, or why, the medication's path becomes unknowable.
Oxycodone and morphine are Schedule II opioids. Clonazepam and lorazepam are Schedule IV benzodiazepines. Both drug classes carry serious risks in elderly nursing home populations, where residents are often on multiple medications simultaneously and where an unexpected dose can cause respiratory depression, sedation, or falls.
The inspection was triggered by a complaint, not a routine survey. That means someone, a resident, a family member, another staff member, contacted regulators before inspectors arrived. The report does not identify who filed the complaint or what initially prompted it.
The narcotic logs themselves, the paper-and-signature records nursing homes use to track controlled substances dose by dose, are designed precisely to catch this kind of discrepancy. Every time a controlled substance is pulled from a facility's supply, a nurse signs for it. The signature is supposed to match an entry in the patient's electronic medication record. When it doesn't, something went wrong, whether through error, negligence, or deliberate diversion.
Here, across four different residents, the signatures and the records did not match, again and again, across weeks.
The Director of Nursing's account of the investigation suggests the facility moved to terminate Staff B relatively quickly once the pattern became visible. But the pattern itself spans from July 22 to August 3, twelve days of documented discrepancies before the picture became clear enough to act on. The inspection report does not indicate when the facility first identified the problem internally or whether any of the affected residents or their families were notified.
Linden Grove Health Care Center is a skilled nursing facility in Puyallup, a city south of Tacoma in Pierce County. The inspection was conducted on August 20, 2025.
For the residents whose names appear only as numbers in the inspection report, the central question has no clean answer in the public record: did they receive medications they weren't supposed to receive, or did someone else receive medications that were supposed to be theirs? Either possibility carries its own consequences, and the inspection report, by its nature, can only document what the records show and what they don't.
What the records show is that someone signed for those doses. What they don't show is where the drugs went.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Linden Grove Health Care Center from 2025-08-20 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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
LINDEN GROVE HEALTH CARE CENTER in PUYALLUP, WA was cited for violations during a health inspection on August 20, 2025.
The discrepancies stretched across at least four residents and nearly six weeks.
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.