Linden Grove Health Care Center
LINDEN GROVE HEALTH CARE CENTER in PUYALLUP, WA — inspection on October 9, 2025.
Found 1 citation. 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
had, anxiousness, as evident by rolling in bed, restlessness, verbalizing [the] pain and discomfort.An SBAR (Situation Background Assessment Recommendation form used as a provider communication tool), dated 09/23/2025 at 7:17 PM, documented Resident 1 had a change in condition related to fever and pain (uncontrolled).
The Pain Status Evaluation area of the SBAR documented Resident 1 had pain at the Genitourinary (includes the penis) area.
Review showed there was no physical assessment documentation related to Resident 1's Foley Catheter included. Resident 1 was sent to the hospital for further evaluation.An ER triage note, dated 09/23/2025 at 5:32 PM, documented Resident 1 reported penile pain at the Foley catheter insertion site.A hospital provider note, dated 09/23/2025 at 8:55 PM, documented Resident 1 reported having pain at the Foley catheter insertion site since the insertion occurred.An Urology provider note, dated 09/24/2025 at 7:49 PM, documented the following: Upon admission [to the hospital] Resident 1's Foley catheter was exchanged.
This led to resolution of the penile pain he had been dealing with.
Today's examination findings show a significant meatal erosion (a breakdown of the outer layers of skin around the opening that leads to the bladder to the to the right and to the left).On 09/25/2025 at 8:00 AM, CC 13, a hospital wound nurse, documented wound care orders that included daily cleansing with normal saline, soap, water, and leaving the wound open to air due to Pressure injury stage Mucosal Membrane (MMPI).
During an interview 10/09/2025 at 1:43 PM, Staff A, Registered Nurse & Director of Nursing, said she would expect Resident 1 to have provider Foley catheter care and monitoring orders on Resident 1's eTAR and a Foley catheter care plan that included care and monitoring interventions.
Staff A said she would expect ensuring catheter tubing was relaxed, not pulling and as needed cleansing around the insertion site to be included in the orders and on the care plan.
After reviewing Resident 1's records, Staff A said there were no Foley catheter care or monitoring care planned interventions and Foley catheter care and monitoring was not included on Resident 1's September 2025 eTAR.
Reference WAC 388-97-1060-1
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