Linden Grove Health Care Center

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 53 505485 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 REFER TO

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 Level of Harm - Minimal harm or 01/29/2025: The facility failed to periodically review a resident's advanced directive (AD, a legal document 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 Residents Affected - Some for a person who is unable to do so for themselves) documentation for 1 of 2 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.

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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.

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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.

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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.

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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.

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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.

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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).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 53 505485 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 REFER TO

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 Level of Harm - Minimal harm or Resident Review (PASARR, a mental health screening tool) assessments were accurately or timely potential for actual harm completed for 2 of 7 sampled residents.

Residents Affected - Some On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of the concerns in this area.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 53 505485 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 REFER TO

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 Level of Harm - Minimal harm or with professional standards of practice for 1 of 2 sampled residents. 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. Residents Affected - Some 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.

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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.

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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.

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F-F758 (D) Free from Unnecessary Psychotropic Medications/as need (PRN) use: Previous deficiency dated 10/2022 (D), and 01/26/2024 (E). The Long Term Care survey dated 01/29/2025: the facility failed to conduct gradual dose reduction (GDR, a trial attempt to discontinue a medication) were free from excessive dosages and durations without adequate monitoring and indications for use, or in the presence of adverse consequences, related to the use of psychoactive (affecting the mind) medications for 1 of 5 sampled residents.

On 01/29/2025 at 1:34 PM, Staff A stated the QAPI committee was not aware of concerns in this area.

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)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 53 505485

F-F865 (E) Quality Assurance and Performance Improvement (QAPI) Program/Plan, Disclosure/Good Faith Attempt.

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):

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