Linden Grove Health Care Center
LINDEN GROVE HEALTH CARE CENTER in PUYALLUP, WA — inspection on January 29, 2025.
Found 22 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F552 (E) Right To Be Informed and make Treatment Decisions: Previous deficiency dated 11/2018 (D), 11/2019 (D), 10/2022 (D), and 01/26/2024 (D).
The Long Term Care survey dated 01/29/2025:
The facility failed to have psychotropic medication (medications that affect a person's mental state) consents completed, signed, and in place prior to residents receiving these medications for 3 of 5 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the facility was cited for this area and found back in compliance.
Staff A stated he did not know why compliance was not maintained and would have to review.
505485
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505485 B.
Wing 01/29/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373
F-F578 (D) Request/Refuse/Discontinue Treatment; Formulate Advance Directive: Previous deficiency dated 11/2018 (E), 11/2019 (E), and 01/26/2024 (D).
The Long Term Care survey dated
potential for actual harm that states your wishes for medical care if you are unable to make decisions for yourself) and obtain and maintain a court-appointed guardianship (legal process where a court appoints someone to make decisions
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO
F-F584 (D) Safe/Clean/Comfortable/Homelike Environment: Previous deficiency dated 11/2018 (E), 11/2019 (D), and 01/26/2024 (D).
The Long Term Care survey dated 01/29/2025: the facility failed to provide a safe, sanitary, and homelike environment for 1 of 4 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO
F-F604 (D) Right To Be Free From Physical Restraints: Previous deficiency dated 12/05/2024 (D).
The Long Term Care survey dated 01/29/2025: the facility failed to obtain provider's order, assessment and consent for the use of a low bed for 3 of 3 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO
F-F609 (E) Reporting of Alleged Violations.
The Long Term Care survey dated 01/29/2025: the facility failed to identify and investigate allegations of abuse/neglect for 6 of 7 sampled residents.
REFER TO
F-F623 (D) Notice Requirements Before Transfer/Discharge: Previous deficiency dated 11/2019 (E) and 01/26/2024 (D).
The Long Term Care survey dated 01/29/2025: the facility failed to provide written notification of the reason for transfer to the hospital to resident or responsible party for 2 of 4 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO
F-F625 (D) Notice Of Bed Hold Policy Before/upon Transfer: Previous deficiency dated 11/2019 (E).
The Long Term Care survey dated 01/29/2025: the facility failed to provide written bed hold notice at the time of transfer to the hospital for 2 of 4 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO
F-F641 (D) Accuracy Of Assessments: Previous deficiency dated 10/2022 (D).
The Long Term Care survey dated 01/29/2025: the facility failed to accurately assess the status for 1 of 5 sampled residents reviewed for Pre-Admission Screening and Resident Review (PASARR, a mental health screening tool).
505485
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505485 B.
Wing 01/29/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373
F-F645 (D) Pre-admission Screening and Resident Review: Previous deficiency dated 01/26/2024 (D).
The Long Term Care survey dated 01/29/2025: the facility failed to ensure Pre-Admission Screening and
potential for actual harm completed for 2 of 7 sampled residents.
REFER TO
F-F656 (D) Develop/Implement Comprehensive Care Plan: Previous deficiency dated 11/2019 (D) and 10/2022 (D).
The Long Term Care survey dated 01/29/2025: the facility failed to develop and implement comprehensive person-centered care plans for 2 of 24 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO
F-F657 (D) Care Plan Timing and Revision: Previous deficiency dated 11/2018 (D), 11/2019 (E), and 01/26/2024 (E).
The Long Term Care survey dated 01/29/2025: the facility failed conduct timely care planning meetings with residents or responsible party for 2 of 4 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO
F-F658 (D) Services Provided Meet Professional Standards: Previous deficiency dated 10/2022 (D).
The Long Term Care survey dated 01/29/2025: the facility failed to meet professional standards of practice for 1 of 5 sampled residents reviewed for use of unnecessary medications.
REFER TO
F-F684 (E) Quality Of Care: Previous deficiency dated 01/26/2024 (E).
The Long Term Care survey dated 01/29/2025: the facility failed to ensure a mobility device was available for 1 of 5 sampled residents and failed to implement a bowel program for 2 of 5 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was aware of this area of concern depending on what it is.
REFER TO
F-F686 (E) Treatment/Services to Prevent/Heal Pressure Ulcer.
The Long Term Care survey dated 01/29/2025: the facility failed to ensure an ordered intervention (Low Air Loss Mattress - LALM, a mattress used to redistribute pressure evenly and can help prevent pressure ulcers, also known as bedsores) was being monitored and used as directed in the prevention of pressure ulcers for 3 of 7 residents.
REFER TO
F-F689 (D) Free of Accident Hazards/Supervision/Devices: 11/2018 (D), 11/2019 (D), 10/2022 (E), and 01/26/2024 (D).
The Long Term Care survey dated 01/29/2025: the facility failed to ensure risk factors were consistently monitored and addressed to minimize the risk for accident hazards for 2 of 7 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO
F-F692 (D) Nutrition/Hydration Status Maintenance: Previous deficiency dated 10/2022 (D).
The Long Term Care survey dated 01/29/2025: the facility failed to ensure the facility's Registered Dietician's (RD) recommendations were administered as ordered to prevent continued weight loss for 1 of 3 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
505485
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 505485 B.
Wing 01/29/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373
F-F695 (D) Respiratory/Tracheostomy Care and Suctioning: Previous deficiency dated 11/2018 (D).
The Long Term Care survey dated 01/29/2025: the facility failed to provide respiratory care consistent
potential for actual harm On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.
REFER TO
F-F727 (E) Registered Nurse 8 Hours/Seven days/Week, Full Time Director of Nursing Services: Previous deficiency dated 11/2019 (F) and 05/30/2024 (F).
The Long Term Care survey dated 01/29/2025: the facility failed to ensure there was a registered nurse (RN) working a minimum of eight hours each day for 60 of 92 days.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was aware of this area of concern and were actively trying to recruit.
REFER TO
F-F756 (D) Drug Regimen Review, Report Irregularities, Act on pharmacist recommendations: Previous deficiency dated 11/2018 (D).
The Long Term Care survey dated 01/29/2025: the facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations and/or to have clearly documented rationale for not following the recommendation for 1 of 5 sampled residents.
REFER TO
F-F757 (E) Drug Regimen Is Free from Unnecessary Drugs: Previous deficiency dated 10/2022 (D), and 01/26/2024 (E).
The Long Term Care survey dated 01/29/2025: the facility failed to provide non-pharmacological (non-medicated) interventions (NPI) prior to as needed (PRN) pain medications for 6 of 8 sampled residents.
On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of concerns in this area.
REFER TO
During an interview on 01/29/2025 at 1:34 PM, Staff A stated the QAA Committee meet once a quarter and sometimes monthly.
Staff A stated the QAA committee know when an issue arose in any department by reviewing grievances, complaints, and results from audits.
Staff A stated the QAA committee knew corrective action had been implemented by utilizing Performance Improvement Plans (PIPs) and reviewing the action plan to ensure it was implemented with audits turned in for review.
When asked why there were repeated citations in various areas of concern, Staff A stated the Director of Nursing Services had been there a year; we continue to work to make improvements. We have had some key staff on leave and new staff trying to step up and help out.
Staff A stated QAPI was effective in some areas; however, they needed to improve in other areas.
Reference WAC 388-97-1760(1)(2)
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During an interview on 01/29/2025 at 1:34 PM, Staff A stated the above listed areas had not been a concern prior to survey.
<Sustain Plan of Corrections>
Refer to the following citations identified during survey which had ineffective plans of correction to sustain correction by the QAPI program which led to repeated deficiencies and pattern of deficiencies. (D = Isolated, E = Pattern):
REFER TO