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Complaint Investigation

Linden Grove Health Care Center

Inspection Date: August 20, 2025
Total Violations 1
Facility ID 505485
Location PUYALLUP, WA
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Inspection Findings

F-Tag F0760

Pharmacy Service Deficiencies
Harm Level: Immediate Jeopardy

F 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

received a dose of lorazepam (a Schedule 4 controlled narcotic medication to treat anxiety) on 08/02/2025 at 11:02 PM, which was not documented in Resident 4's eMAR. Review of the narcotic log showed that Resident 5 received doses of clonazepam (a Schedule 4 controlled narcotic medication to treat anxiety) on 07/22/2025 at 6:00 PM; 07/24/2025 at 4:00 AM and 8:00 PM; 07/26/2025 at 10:00 AM; 07/27/2025 at 9:00 PM; 07/28/2025 at 9:00 PM; 07/30/2025 at 9:00 PM; 07/31/2025 at 8:00 PM, and oxycodone on 07/26/2025 at 4:00 AM and 10:00 AM; 07/27/2025 at 4:00 AM and 7:00 PM; 07/28/2025 at 1:00 AM; 07/29/2025 at 4:00 PM and 10:00 PM; 07/30/2025 at 4:00 AM, 9:00 AM and 5:00 PM; 07/31/2025 at 6:00 PM; 08/01/2025 at 1:00 AM; 08/03/2025 at 8:43 AM, none of which were documented in Resident 5's eMAR. Review of the narcotic log showed that Resident 6 received doses of oxycodone on 07/31/2025 at 6:00 PM and 08/01/2025 at 2:00 AM, neither of which were documented in Resident 6's eMAR. In an interview on 08/14/2025 at 2:30 PM Staff A, Director of Nursing Services (DNS), stated that when Staff B, LPN, was questioned about why the extra dose of morphine was signed out of Resident 2's narcotic book, Staff B, LPN, stated I don't know. Staff A, DNS, stated that based on the facility investigation and pattern of incorrect narcotic administration documentation, Staff B, LPN's, employment was terminated. Reference WAC 388-97-1060 (3)(k)(iii).

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📋 Inspection Summary

LINDEN GROVE HEALTH CARE CENTER in PUYALLUP, WA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PUYALLUP, WA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LINDEN GROVE HEALTH CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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