Linden Grove Health Care Center

self-administer medications.

Staff B stated they were told last night (01/07/2026) that Resident 114

WAC 388-97-0440, -1060(3)(I)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

During an interview on 01/09/2026 at 10:35 AM, Resident 4 stated they had been waiting for a haircut and had informed staff multiple times. Resident 4 stated upon admission the facility had a hairdresser who came regularly but had not been providing services for several months.

During an interview on 01/09/2026 at 10:39 AM, Staff BB, Receptionist, stated they had been responsible for coordinating grooming appointments by communicating resident requests to the hairdresser.

Staff BB stated hairdresser services had not been available for approximately one and a half years.

Review of Resident Council Minutes dated 09/08/2025 showed a resident concern related to when the facility would have a hairdresser taking appointments.

Resident Council Minutes dated 10/06/2025 showed the response to the concern: An offer was made to a hairdresser by the facility, and they were waiting to see if the offer was accepted.

Resident Council Minutes dated 11/12/2025 showed and updated that the facility and the hairdresser were in wage negotiations.

Review of the admission Packet document entitled Facility Rules, undated, showed, Salon Services- Please see Social Services Department for a listing of services, to schedule an appointment and pricing information.

During an interview on 01/12/2026 at 12:33 PM, Staff B, Director of Nursing Services (DNS), stated the facility did not currently have a hairdresser.

Staff B stated the last consistent hairdresser they had was in 2023, but they were working on hiring someone.

Staff B stated the expectation was residents who wanted haircuts should have been accommodated.

Reference WAC 388-97-2280

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

During an interview on 01/13/2026 at 10:41 AM, Staff M, Business Office Manager (BOM), stated a SNF ABN should be provided the same day as the NOMNC.

Staff M stated they should have had Resident 93's SNF ABN form signed on the same day the NOMNC was signed on 07/30/2025.

During an interview on 01/13/2026 at 2:24 PM, Staff A, Administrator, stated their expectation was that SNF ABN be provided no more than 48 hours when the last covered date of Part A Service had been determined and the resident was to remain in the facility.Staff A stated Resident 93's SNF ABN dated 08/04/2025 was not signed timely and did not meet their expectations. Resident 23 Review of a NOMNC, dated 09/19/2025, showed the facility informed Resident 23 skilled nursing services would end on 09/21/2025 and the form was signed by the resident or representative on 09/10/2025. Resident 23's SNF ABN dated 09/19/2025 showed it was not signed by the resident or a representative.

During an interview on 01/13/2026 at 10:41 AM, Staff M, BOM, stated whoever completed the NOMNC for Resident 23 on 09/19/2025 did not get a signature for the resident's SNF ABN dated 09/19/2025 and this did not meet their expectations.

During an interview on 01/13/2026 at 2:24 PM, Staff A, Administrator, stated Resident 23's SNF ABN dated 09/19/2025 should have been signed by the resident or representative and this did not meet their expectations.

Reference WAC 388-97-0300(1)(e)(5)(6)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Findings included.

Review of the electronic health record (EHR) showed Resident 8 was admitted to the facility on [DATE] with diagnoses to include hemorrhage in brain stem (bleeding in brain stem), depression, anxiety, and cognitive communication deficit. Resident 8 was not always able to communicate needs.

Observation on 01/05/2026 at 9:55 AM showed Resident 8 in their room with a bed frame that had exposed metal frame.

Observation on 01/07/2026 at 8:56 AM, showed Resident 8 in their bed with second bed near them with no mattress or covers.

Observation on 01/08/2026 at 9:56 AM showed Resident 8 laying in their bed with bed frame nearby with no mattress and no covers.

Observation on 01/09/2026, 01/12/2026, and 01/13/2026 showed Resident 8 in their room with the bed frame with no mattress and no covers.

During an interview on 01/13/2026 at 10:34 AM, Staff H, Assistant Director of Nursing/Licensed Practical Nurse (ADON/LPN), stated the bed should be made and have a mattress, that was not a homelike environment and did not meet expectations.

Reference WAC 388-97-0880

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Findings included.

Review of the facility's policy Use of Restraints, undated, showed under section 1 Physical Restraints were defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restrict normal access to one's body and under section 16, The assessment reviews are to be at least quarterly to determine reduction.

Review of the electronic health record (EHR) showed Resident 13 was admitted to the facility on [DATE] with diagnoses to include dementia (term for decline in mental abilities including thinking, memory and reasoning), asthma (chronic lung disease causing narrow airways), hypertension (elevated blood pressure), and malnutrition. Resident 13 was able to communicate needs.

Review of the annual minimum data set assessment (MDS), dated [DATE], showed Resident 13 was using a Wander Guard daily.

During an interview and observation on 01/05/2026 at 3:22 PM, Resident 13 stated they would like to go outside, but whoever takes me outside needs to get a star and was pointing towards their left wrist wander guard bracelet.

Review of the EHR showed a document called Restraint Evaluation/Reduction dated 02/28/2025 with recommendation/Plan to re-evaluate in six months.

During an interview on 01/08/2026 at 2:23 PM, Staff J, Licensed Practical Nurse, stated when residents were actively going out of the facility they got a wander guard, and were not sure on how frequently the residents should be reassessed.

During an interview on 01/09/2026 at 12:50 PM, Staff B, Director of Nursing Services, stated the reassessment of Resident 13's Wander Guard should have been done sooner and that did not meet the expectation.

Reference WAC 388-97-0620

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

During an interview on 01/14/2025 at 10:40 AM, Staff B, DNS, stated psychotropic medications should be used to treat specific diagnoses.

Staff P stated Resident 115 received antidepressants, did not have a diagnosis of depression, and this did not meet expectations.

Staff B stated facility nursing staff should have contacted the provider to notify them of the lack of depression diagnosis.

Reference WAC 388-97-0620(1)(a)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

background checks were to be completed upon hire and Staff C and D background checks did not

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

the State Hotline as soon as possible and/or within two hours.

Staff A stated that intention of

perceived them.

Staff A stated that after they talked to Resident 46 on 01/11/2026 they were able to

never told them that they felt ashamed by the volunteers.

Staff A stated that Staff N, Activity Director, had not told them that it was relayed to them that they thought Resident 46 felt shamed by the volunteers for being gay.

Staff A stated that this should have been reported to the abuse hotline, the Director of Nursing Services and to myself and an incident investigation initiated at that time.

Reference WAC 388-97- 0640(5)(6)(a)(c)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Review of the EHR showed Resident 111 discharged from the facility on 11/13/2025.

The EHR did not have documentation detailing the discharge.

During an interview on 01/13/2026 at 10:13 AM, Resident 111 stated they left the facility against medical advice on 11/13/2025 due to the conditions at the facility. Resident 111 stated staff were aware of the discharge which was in the afternoon. Resident 111 stated the facility did not provide them with any medications or paperwork.

During an interview on 01/14/2026 at 9:54 AM, Staff V, Social Services Assistant (SSA) stated when residents discharge the Discharge Planned Documentation assessment (discharge summary) in the medical record was to be completed for all residents.

Staff V stated they were unable to locate documentation of a completed assessment for Resident 111.

During an interview on 01/14/2026 at 10:08 AM, Staff A, Administrator, stated the expectation was that all discharge documents to include the discharge summary were completed for all residents including self-initiated discharges.

Staff A stated the document should have been provided to the resident/resident representative by mail.

Reference WAC 388-97-0120(4)(b)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Review of the EHR showed Resident 40 readmitted to the facility on [DATE] with diagnoses to include personality disorder (a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that causes problems), schizophrenia (mental disorder that affects how a person thinks, feels, and behaves, leading to disorganized thinking), and post-traumatic stress disorder (PTSD, a mental health condition where someone feels stressed and scared long after a traumatic event). Resident 40 was able to make needs known.

Review of Resident 40's EHR showed a level 2 PASSAR was completed on 05/01/2020.

Review of the care plan dated 10/19/2022 showed Resident 40 met PASSAR level 2 determination related to diagnoses of serious mental illness.

Review of Resident 40's MDS dated [DATE] section A1500 showed Resident 40 was coded No. for having a PASSAR level 2 with serious mental illness.

During an interview on 01/08/2026 at 1:06 PM, Staff G, MDS Nurse, stated Resident 40's admission MDS dated [DATE] was coded incorrectly and should have been coded yes for having a PASSAR level 2 with serious mental illness.

During an interview on 01/08/2026 at 2:14 PM, Staff B, DNS, stated Resident 40's admission MDS dated [DATE] was not coded correctly for level 2 PASSAR and should have been coded Yes.

Staff B stated Resident 40's admission MDS needed to be modified.

Reference WAC 388-97-1000(1)(b)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Review of the Electronic Health Record (EHR) showed Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include hemorrhage in brain stem (Bleeding in brain stem), gastrostomy (surgically placed external opening into stomach), major depression, anxiety, psychotic disorder with delusions ( fixed, false beliefs held with extraordinary conviction despite clear evidence of the contrary) and cognitive communication deficit. Resident 8 was not always able to communicate needs.

Review of the provider's orders dated 12/31/2025 showed Resident 8 was to have nothing by mouth (NPO) status.

Observation on 01/05/2026 at 9:55 AM, showed Resident 8 in their room with a pole and machine that was connected to a bag of water and a tube feeding formula, being administered liquids into their stomach via a tube.

Review of the care plan dated 11/22/2024 Showed Resident 8 with focus area Resident exhibits or is at risk for Dehydration, there were no instructions on how Resident 8 was to receive fluids.

During an interview on 01/09/2026 at 12:44 PM, Staff B, Director of Nursing Services (DNS), stated the expectation was for Residents that have NPO status to have a care plan and directives for staff on how they receive fluids.

Staff B stated the care plan for Resident 8 did not meet expectations. Resident 17 Review of the EHR showed Resident 17 admitted to the facility on [DATE] with diagnoses of chronic pain syndrome and major depressive disorder.

The resident was able to make needs known.

Review of the plan of care dated 01/06/2026 for Resident 17 showed the resident required two caregivers for all interactions, care in pairs.

Observation and interview on 01/09/2026 at 11:22 AM showed Staff C, Certified Nursing Assistant (CNA) was providing a brief change and personal hygiene to Resident 17.

When asked if Resident 17 required care in pairs, Staff C stated No.

During an interview on 01/12/2026 at 9:12 AM, Staff B, DNS, stated it was their expectation that staff followed the plan of care and if a resident required care in pairs they have a second staff member for all interactions.

Reference WAC 388-97-1020(1),(2)(a)(b)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Review of Resident 51's EHR on 01/08/2026 did not show the resident was actively positive for Covid.

During an interview on 01/12/2026 at 1:34 PM, Staff R, Licensed Practical Nurse (LPN), stated Resident 51's care plan showed an intervention for oxygen at three liters, but the resident's current order was for four liters, and the care plan needed to be revised.

Staff R stated Resident 51's focused care plan for at risk for complications related to Covid needed to be revised because Resident 51 did not have Covid.

During an interview on 01/12/2026 at 2:34 PM, Staff B, DNS, stated Resident 51's current care plan did not meet their expectations because it showed the resident's oxygen liter flow was three liters and had risk for respiratory complications related to Covid; however, Resident 51's oxygen order was for four liters and the resident did not have Covid.

Staff B stated that Resident 51's care plan needed to be revised.

Reference WAC 388-97 -1020(3)(5)(b)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Review of the electronic health record (EHR) showed Resident 114 admitted to the facility on [DATE] with diagnoses to include cerebral infarction (a type of stroke where part of the brain dies because its blood supply gets blocked), high blood pressure, and atherosclerosis (narrowing of blood vessels, restricting blood flow) of both legs. Resident 114 was able to make needs known.

During an interview on 01/07/2026 at 9:15 AM, Resident 114 stated their left heel was sensitive and they were supposed to wear a boot on their left heel, but the staff forgot about it. Resident 114 stated that staff had told them a couple of times that they were going to get a boot for their left foot, but they never got it.

Multiple observations on 01/07/2026 at 9:15 AM, 01/08/2026 at 8:50 AM, 01/09/2026 at 10:16 AM, and 01/12/2026 at 1:51 PM showed Resident 114 lying in bed with no boot in place on the left foot.

Review of the admission minimum data set assessment (MDS) dated [DATE] showed Resident 114 was at risk of developing a pressure ulcer/skin wound injury.

Review of the provider order dated 10/14/2025 showed Resident 114 was to have a foam boot applied to the left foot every shift for left heel protection.

Review of Resident 114's focused care plan for skin breakdown initiated on 09/17/2025 showed no intervention for a foam boot to the left foot.

During an interview on 01/09/2026 at 9:09 AM, Staff U, Certified Nursing Assistant (CNA), stated they had never seen Resident 114 wear a foam boot on their left foot.

Staff U stated Resident 114's care plan and Kardex (directions/information used to provide care to the residents) did not show that they were to have a foam boot placed on the left foot.

During an interview on 01/12/2026 at 1:51 PM, Staff R, Licensed Practical Nurse, stated Resident 114 did not have a foam boot to the left foot in place and was unable to locate a boot in the resident's room.

Staff R stated Resident 114 had a provider order dated 10/14/2025 to apply a foam boot to the left foot every shift for left heel protection.

Staff R stated Resident 114's January 2026 treatment administration record (TAR) showed documentation that the foam boot had been applied; however, they knew it had not been applied, and this did not meet expectations.

During an interview on 01/12/2026 at 2:11 PM, Staff B, Director of Nursing Services, stated Resident 114 had an order for a foam boot to the left foot and the January 2026 TAR showed it was being documented it had been applied every shift; however, it was not.

Staff B stated Resident 114's provider's order should have been followed, and this did not meet expectations.

Reference WAC 388-97- 1620(2)(b)(i)(ii),(6)(b)(i)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

During an interview on 01/12/2026 at 2:06 PM, Staff B, DNS, stated they were not aware that Staff S,

however, both Resident 99 and Staff S stated the shower was not provided.

Staff B stated showers were not consistently offered/provided or documented as required and this did not meet their expectations. Resident 17 Review of the EHR showed Resident 17 admitted to the facility on [DATE] with diagnoses of chronic pain syndrome and major depressive disorder.

The resident was able to make needs known.

During an interview and observation on 01/06/2026 at 10:21 AM, Resident 17 stated I have not had a shower or bed bath since May they don't help me wash my face or brush my hair or teeth, they only come in if i call them. Resident 17 had a brown and white substance on their teeth and a visible knot in their hair.

Review of Resident 17s care plan dated 02/05/2025 showed the resident required one staff maximum assistance with bed baths, personal hygiene and oral care.

Review on 01/06/2026 of Resident 17's point of care documentation for bathing showed four documented bed baths in the prior 30 days provided by Staff Q, Certified Nursing Assistant (CNA).

Review of the shower schedule for the 100's hall on 01/12/2026 located in front of a binder at the south nurse's station showed a schedule for day shift and evening shifts.

Review showed Resident 17's room/bed was scheduled to have a shower on Monday on the day shift (one day a week).

During an interview on 01/12/2026 at 1:06 PM, Staff R, Licensed Practical Nurse stated the facility does not have a shower aide right now and the CNA's on the floor should provide the showers.

During an interview on 01/07/2026 at 9:09 AM, Staff Q stated they did not wash their hair during a bed bath and they did not offer oral care or hair brushing to Resident 17 unless they ask.

Staff Q stated they used the shower/bathing documentation to document a skin condition they had noticed but had not provided a bed bath.

During an interview on 01/09/2026 at 11:22 AM, Staff C, CNA stated they only gave bed baths/showers if a resident requests, and Resident 17 would request supplies if they wanted to brush their teeth or hair.

When asked if setting up Resident 17 for brushing teeth and washing face and hands was part of morning care, Staff C stated No.

During an interview on 01/12/2026 at 9:12 AM, Staff B, DNS, stated it was their expectation that the assigned CNA's should provide showers/bed baths if they did not have a shower aide.

Staff B stated it was their expectation that morning care for all residents includes setting the residents up to wash their face, and brush their hair and teeth.

Reference WAC 388-97 -1060(2)(c)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

During an interview on 01/07/2026 at 8:47 AM, Resident 40 stated their refrigerator was clean and organized and there was no need to look in it. Resident 40 stated they only kept water and milk in the refrigerator, no food, and the freezer had ice cream and milk.

During an interview and observation on 01/12/2026 at 8:58 AM, Staff EE, Certified Nursing Assistant (CNA), stated they were not sure where Resident 40 was; however, they were not in their room at this time.

Staff EE stated they would usually put milk or ice cream in the freezer for Resident 40.

Staff EE opened the refrigerator, and it had three containers of Ensure Plus that expired on 01/10/2026, a container of dressing that expired on 01/04/2026, a green salad that expired on 01/09/2026, a half of a sandwich in a plastic bag with unidentifiable/label dated 12/2.

Staff EE opened the freezer and showed ice cream and a cup of liquid dated 01/15/2026 and all items were frozen solid.

Staff EE stated expired food items should not be in the refrigerator.

Staff EE showed a refrigerator temperature log tapped to the side of the refrigerator dated January 2026 that was blank and showed the dates of one (1) through nine (9) crossed out with a line and the rest of the dates of the month were blank.

Staff EE stated they were not sure who was responsible for cleaning and checking items in the refrigerator or filling out the temperature log but would find out.

During an interview on 01/12/2026 at 9:27 AM, Staff EE, CNA, stated Staff R, LPN, told them the CNAs were to clean the refrigerators and to remove the expired items from Resident 40's refrigerator.

During a follow-up interview on 01/12/2026 at 9:37 AM, Staff EE, CNA, stated Staff R, LPN, told them that the CNAs were to log refrigerator temperatures when they cleaned the refrigerator daily.

During an interview on 01/13/2026 at 2:29 PM, Staff B, DNS, stated the licensed nurses were responsible for cleaning the refrigerators, checking food to ensure food had dates and were removed prior to expiration, checking the refrigerator temperatures and logging them on the temperature log.

Staff B stated they were not aware that Resident 40 had expired food items in their refrigerator and that the refrigerator temperature log was not filled out.

Staff B stated this did not meet their expectations. <Unsecured Chemicals> Observation and interview on 01/07/2026 at 8:47 AM showed a container of Clorox 2/Stain Remover and a container of Woolite, and both chemicals were located unsecured on top of the toilet tank cover in Resident 40's bathroom. Resident 40 stated those were their personal items.

During an interview on 01/12/2026 at 9:27 AM, Staff EE, CNA, stated the container of Clorox and Woolite on the back of Resident 40's toilet tank both showed, Keep out of reach of children on the labels.

Staff EE stated those items should be locked up for safety.

During a follow-up interview on 01/12/2026 at 9:37 AM, Staff EE, CNA, stated Staff R, LPN, told them to remove the chemicals from Resident 40's bathroom and bring the chemicals to them for safekeeping.

During an interview on 01/13/2026 at 2:29 PM, Staff B, DNS, stated chemicals should be in a locked cabinet or area and should not be kept unsecured in a resident's bathroom.

Staff B stated they were not aware Resident 40 had unsecured chemicals in their bathroom and this did not meet their expectations.

Reference WAC 388-97- -1060(3)(g)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Findings included.

Review of the electronic health record showed Resident 5 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder (mental health condition with significant mood swings) and adult failure to thrive (significant decline in health and functional abilities). Resident 5 was able to make needs known.

Review of Resident 5's EHR showed Resident 5 weighed 147 pounds on 11/10/2025 and 123 pounds on 12/02/2025.

Review of a progress note dated 12/05/2025 showed, Weight warning: MDS: five percent change over 30 days.

Resident noted with variable meal intake, order placed to reweigh.

Review of the EHR showed no documentation Resident 5 was reweighed nor were any additional weights taken.

Review of a Change of Condition Evaluation dated 01/06/2025 completed by Staff J, Licensed Practical Nurse (LPN), showed it was reported that Resident 5 had a five percent weight loss within the past 30 days.

Review showed the provider was notified on 01/06/2026 and recommended the facility to monitor.

Review of Resident 5's care plan showed no new interventions related to monitoring the resident's weight.

Review of Resident 5's EHR showed meal intake was not documented for all meals throughout the day.

During an interview on 01/13/2026 at 12:22 PM, Staff J, LPN, stated when significant weight loss was identified the provider should have been notified the same day.

Staff J stated a weight variance meeting with the Dietician and Director of Nursing should have been conducted but did not.

During an interview on 01/13/2026 at 12:22 PM, Staff B, Director of Nursing Services (DNS), stated when there was a change in condition related to weight loss staff were expected to contact the provider and Dietician within 24 hours.

Staff B stated recommendations from the provider should have been implemented immediately and the lack of monitoring Resident 5's meal intake and weights did not meet expectations.

Reference WAC 388-97-1060 (3)(h)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

The facility failed to have a system in place which ensured the amount of formula (liquid food product) and water a resident receives was reconciled with the amount they were ordered to receive.

This failure placed the Resident at risk for inadequate nutrition, dehydration, and diminished quality of life.

Findings included.

Review of the electronic health record (EHR) showed Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include hemorrhage in brain stem (bleeding in brain stem), gastrostomy (surgically placed external opening into stomach), major depression, anxiety, and cognitive communication deficit. Resident 8 was not always able to communicate needs.

Observation on 01/05/2026 at 9:55 AM showed Resident 8 in their room with a pole and a machine that was connected to a bag of water and a tube feeding formula, administering liquids in their stomach via tube.

Review of the provider's orders dated 12/31/2025 showed Resident 8 had enteral feed order to provide Jevity (formula) at 60 milliliters (ml) every hour for 22 hours starting at 2:00 PM and ending at 12:00 noon, and to have 150 ml of water flush every four hours with total of 1760 ml/2640 calories of formula and 2137 ml of free water.

Review of the January 2026 medication administration record showed Resident 8 was provided 80 ml every day.

During an interview on 01/09/2026 at 12:44 PM, Staff B, Director of Nursing Services, stated the process for documentation of enteral nutrition was to have amount of formula and water documented every shift and total for the day.

Staff B stated documentation for Resident 8's enteral nutrition did not meet expectations.

Reference WAC 388-97-1060(3)(f)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

During an interview on 01/12/2026 at

included O2 Sats parameters of when to notify the provider and this did not meet expectations.

Staff R stated the order needed to be clarified with the provider to include O2 Sats parameters.

During an interview on 01/12/2026 at 2:29 PM, Staff B, DNS, stated Resident 42's O2 orders should be clarified with the provider to obtain O2 Sats parameters.

Resident 51

Review of the EHR showed Resident 51 readmitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease, heart failure, and respiratory failure. Resident 51 was able to make needs known.

Review of Resident 51's Medicare 5-day MDS dated [DATE] showed that the resident received O2 therapy.

Observation on 01/08/2026 at 3:22 PM showed Resident 51 laid in bed with O2 infusing via NC connected to an O2 concentrator with O2 flowing at a rate of 4 liters per minute.

Review of the provider order dated 11/17/2025 showed Resident 51 was prescribed O2 at 4 liters per minute continuously via NC every shift related to COPD.

Post treatment: evaluate heart rate, respiratory rate, pulse oximetry, skin color, and breath sound.

This order did not show parameters for O2 saturation or when to notify the provider related to O2 saturations and O2 therapy.

Review of Resident 51's care plan showed a focused care plan for COPD initiated on 10/04/2020 with an intervention to administer oxygen as order/indicated and to maintain saturation levels greater than or equal to 90% initiated on 10/06/2020.

Review of Resident 51's January 2026 TAR from 01/01/2026 - 01/08/2026 showed an order with a start date of 11/17/2025 for O2 at 4 liters via NC every shift and documentation showed that O2 was provided per orders to include documented O2 Sats; however, the order did not include O2 Sats parameters, and post treatment to evaluate heart rate, respiratory rate, skin color, and breath sound was not documented in the TAR.

During an interview on 01/12/2026 at 1:34 PM, Staff R, LPN, stated Resident 51's O2 order dated 11/17/2025 was missing O2 Sats parameters and the order needed to be clarified with the provider.

Staff R stated this O2 post treatment order to evaluate heart rate, respiratory rate, skin color, and breath sounds were not documented on the TAR; however, it was documented as completed per provider order and if there was a problem then the provider would be notified.

During an interview on 01/12/2026 at 2:34 PM, Staff B, DNS, stated they saw that Resident 51's O2 orders did not have O2 Sats parameters and should have.

Staff B stated that Resident 51's O2 order that included post treatment to evaluate heart rate, respiratory rate, skin color, and breath sound was not documented in the TAR and/or in a progress note or EHR consistently and this did not meet their expectations.

Reference WAC 388-97-1060 (3)(j)(iv)-(vi)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Review of the EHR showed Resident 17 admitted to the facility on [DATE] with diagnosis of chronic pain syndrome.

The resident was able to make needs known.

During an interview and observation on 01/06/2026 at 10:26 AM, Resident 17 stated I am in a lot of pain all the time.

Resident appeared guarded, curled in the bed, and grimacing.

Review of the EHR showed a provider order dated 02/19/2025 for Hydromorphone (a narcotic pain medication) two milligram tablets.

The resident was to receive one tablet for pain levels of 4-6 or two tablets for pain levels of 7-10 every 6 hours as needed for pain.

Review of the January 2026 medication administration record showed Resident 17 reported a pain level of 7 twice on 01/01/2026 and was administered one tablet. On 01/03/2026 the resident reported pain levels of 7 and 8 and received one tablet. On 01/04/2026 the resident reported pain levels of 9 and 8 and received one tablet, and on 01/07/2026 the resident reported pain levels of 8 and 9 and received one tablet.

During an interview on 01/09/2026 at 12:46 PM, Staff H, Licensed Practical Nurse/Assistant Director of Nursing stated it was their expectation that staff follow the parameters in the providers orders, Staff H stated Resident 17's pain medication administration did not meet their expectations.

During an interview on 01/12/2026 at 9:18 AM, Staff B, DNS, stated it was their expectation the nursing staff follow the provider orders and should have administered two tablets for pain levels of 7 or greater for Resident 17.

Reference WAC 388-97 1060(1) -1620(2)(b)(i)(ii)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

During an interview on 01/13/2026 at 11:40 PM, Staff A,

facility had implemented new disciplinary policies related to staff who ?no call no show' or habitually

Dependent ResidentsFed - F - 0730- Nurse Aide Performance Review and 12 Hours and year In-Service

Reference WAC 388-97-1080 (1), 1090 (1)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Findings included .Review of Staff D,

evaluations had been conducted.

During an interview on 01/12/2026 at 3:28 PM, Staff AA, Human Resources/Payroll, stated that they were aware that the CNAs needed performance evaluations yearly; however, they had not been completed.

During an interview on 01/13/2026 at 11:40 AM, Staff A, Administrator, stated due to staff changes, performance evaluations were not completed, and this did not meet expectations.

Reference WAC 388-97-1680

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Review of Resident 99's January 2026 MAR from 01/01/2026 &ndash; 01/08/2026 showed an order for Tylenol 1000 milligrams (mg) by mouth every six hours as needed for a pain level of 1 &ndash; 4 out of 10 with NPI listed, with a start date of 01/02/2026.

Review showed Tylenol was provided on 01/06/2026 for a pain level of 4; however, NPI was documented NA.

During an interview on 01/13/2026 at 10:53 AM, Staff B, DNS, stated Resident 99's January 2026 MAR was documented NA on 01/06/2026 and should have been marked for the NPI provided or refused and this did not meet their expectations.

Reference WAC 388-97-1060(3)(k)(i)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Observation on 01/09/2026 at 8:14 AM, showed Staff Y, Licensed Practical Nurse (LPN), administering medications to include vitamin C 500mg to Resident 7.

Review of the January 2026 medication administration record (MAR) showed Resident 7 did not have an order for Vitamin C 500mg and had received the wrong medication.

Review of the January 2026 MAR showed Resident 7 had an order for cyanocobalamin (vitamin B12) 500mcg that was not administered.

Observation on 01/09/2026 at 7:57 AM showed Staff K, LPN, administering medications to Resident 52 to include Folic acid 1000mcg from an over-the-counter container, and Folic acid 1mg from pharmacy packaging.

Review of the January 2026 MAR showed Resident 52 did not have two orders for folic acid and received the wrong medication.

Review of the January 2026 MAR showed Resident 52 had an order for Prenatal vitamins with ferrous fumarate-folic acid that was not administered.

During an interview on 01/09/2026 at 1:11 PM, Staff B, Director of Nursing Services, stated the licensed nurses were to follow the provider's orders when administering medications and that did not meet expectations.

Reference WAC 388-97-1060(3)(k)(ii)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Based on observation, interview, and record review, the facility failed to secure (lock) 1 of 4

medication storage.

This failure placed residents at risk for medication diversion and misuse, lack of safety, poisoning, and a diminished quality of life.

Findings included.

Review of the Facility's policy titled, Storage of Medications, revised on November 2020, showed, Drugs and biological used in the facility are stored in locked compartments under proper temperature, light and humidity controls.

Only persons authorized to prepare and administer medications have access to locked medications.

Observation on 01/07/2026 at 10:56 PM, showed the treatment Cart South 2 was unlocked without nurse supervision for 10 minutes.

Staff X, Licensed Practical Nurse (LPN), was called to lock the cart.

During an interview on 01/07/2026 at 11:00 PM, Staff X stated the nurse responsible for Cart South 2 was on break.

Staff X stated the cart should have been locked.

Observation on 01/09/2026 at 7:38 AM, showed Staff Y, LPN, was administering medication to a resident and left the medication Cart South 3 unlocked and not in visual supervision while turning towards the Resident to administer medications.

During an interview on 01/09/2026 at 1:11 PM, Staff B, Director of Nursing Services (DNS), stated the medication and treatment carts should have been locked when nurses were not next to the cart.

Observation on 01/12/2026 at 10:36 PM, showed medication Cart South 3 was left unlocked for eight minutes.

Staff J, LPN, was called to lock the medication cart.

During an interview on 01/12/2026 at 10:44 AM, Staff J, LPN, stated Cart South 3 should have been locked.

During an interview on 01/12/2026 at 1:08 PM, Staff B, DNS, stated the unlocked medication and treatment carts did not meet expectations.

Reference WAC 388-97-1300(2)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Review of Resident Council Minutes, dated 10/06/2025, showed the Dietary Committee section requested better presentation of food to include receiving dry napkins and items placed uniformly on the tray.

Review of Resident Council Minutes, dated 11/10/2025, showed the following concerns during the Dietary Committee section: 1) [NAME] served too often; and 2) Vegetables regularly overcooked.

Review of Resident Council Minutes, dated 12/08/2025, showed the following concerns during the Dietary Committee section: 1) Vegetables often served overcooked; 2) [NAME] served too often; 3) Breakfast frequently served cold; and 4) Not receiving requested alternative items.

Review showed the Resident Council requested an explanation why they were told basic items were unavailable and reported they had been told by staff there was no sugar, bread, jelly, fruit, etc at various times the previous month. <GRIEVANCES> Review of a Complaint/Grievance Report, dated 07/02/2025, showed Resident 120 reported, When my meals come, they're cold, but my liquids are warm.

Review of a Complaint/Grievance Report, dated 07/09/2025, showed Resident 121 reported, Food is crap.

Review of a Complaint/Grievance Report, dated 07/18/2025, showed Resident 49 reported, I haven't been able to eat any of the meals for five days. No silverware, only plastic. I wouldn't serve it to a dog.

Review of a Complaint/Grievance Report, dated 07/18/2025, showed Resident 102 reported, No silverware.

The food is awful here.

Not edible. It tastes like [expletive].

Review of a Complaint/Grievance Report, dated 07/29/2025, showed Resident 122 reported, Kitchen is serving foods [they are] not able to eat.

Review of a Complaint/Grievance Report, dated 07/31/2025, showed Resident 123 reported, I never got a dinner tray last night.

Review of a Complaint/Grievance Report, dated 08/03/2025, showed Resident 123's family member reported Resident 123 had arrived at the facility at 3:00 PM and called them at 8:30 PM to report they had not received a food tray. Resident 123 stated they called the facility at 9:00 PM to request Resident 123 receive food, but they were not provided with a meal until after midnight.

Review of a Complaint/Grievance Report, dated 08/07/2025, showed Resident 123 reported, Filled out menu daily, did not get what they ordered, or they would write it on the ticket in big red letters they ran out.

Review of a Complaint/Grievance Report, dated 08/20/2025, showed Resident 124 reported, Food is horrible and tasteless.

Review of a Complaint/Grievance Report, dated 10/03/2025, showed Resident 37 reported they sometimes received pureed diet, but their ordered diet was regular soft and bite sized.

Review of a Complaint/Grievance Report, dated 10/26/2025, showed Resident 122 reported they were not receiving enough food.

Review of a Complaint/Grievance Report, dated 12/21/2025, showed Resident 78 reported, Not the right breakfast items according to the menu and tray ticket.

Review of a Complaint/Grievance Report, dated 12/29/2025, showed Resident 125 reported concerns about food not being on tray as stated on meal ticket.

Review of a Complaint/Grievance Report, dated 12/31/2025, showed Resident 125 reported they did not like the food they received.

During an interview on 01/14/2026 at 9:17 AM, Staff CC, Dietary Manager, stated the facility held a dietary committee meeting monthly to ensure residents found the facility's food palatable.

Staff CC stated they were aware of concerns related to food quality and felt the issue was with the quality of the product the kitchen was allowed to purchase.

Staff CC stated the frequent concerns with food quality and not receiving requested items did not meet their expectations.

During an interview on 01/14/2025 at 10:22 AM, Staff A, Administrator, stated the expectation was for residents to consider the facility's food to be palatable.

Staff A stated they were aware of the residents' concerns related to palatability of the facility's food and they were working with their regional group to resolve the issue.

Staff A stated the residents' statements, dietary committee concerns, and grievances related to food did not meet expectations.

Reference WAC 388-97-1100(1)(2)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Findings included.

Review of the facility policy titled, Safe Handling of Foods from Visitor, revised 03/28/2024, showed, Label foods with resident's name, and the current date and ?use by date'.

Items will be thrown out after 48 hours and Have temperature monitored daily for refrigeration < 41 F.

Observation on 01/07/2026 at 11:54 PM showed the 100 Hall Resident Refrigerator contained the following items: 1) A bag teriyaki in Styrofoam packaging inside with a receipt showing the order was placed on 01/01/2026; 2) A cup of soup with no date label; 3) A plastic container teriyaki dated 12/08/2025; 4) A box of fried chicken with no date or resident name; 5) A bag with lettuce with brown spot spoilage with no date or name; 6) A half sub sandwich with receipt showing 12/23/2025 pick-up; 7) A container of nutritional formula opened with packaging showing In medical setting throw away after 24 hours with no date label and, when opened, showed dried substance in spout and floating items in formula; 8) A container of French onion dip with best by date of 11/03/2025; 9) Four strawberry banana yogurts with a best by date of 12/12/2025; 10) A Tupperware of vegetable dish with no date label; 11) Two pieces of pizza in original full pie cardboard box with no date label; 12) A plastic to go container of Chinese food with date label of 12/20/2025; 13) A bag with two pieces of cornbread in Ziplock bags and a container with a meal with no date label; 14) An opened water bottle with frozen yellow solid inside with no date label or resident name; 15) A plastic box of grapes with no date label showing grapes were wrinkled; 16) A bag with sandwich makings to include mayo, sliced meat, and lettuce and meat showed sold on 12/02/2025; 17) A plastic box with a pasta dish without date label and resident name; 18) A cardboard takeaway box with unidentifiable food with no date label; and 19) Numerous small plastic containers of condiments with illegible date or a date which was out of range.

Observation on 01/08/2026 at 12:12 AM showed the 200 Hall Resident Refrigerator contained the following items: 1) A bag of fast food with a 01/02/2026 date; 2) A bag with a container of ribs and two fruit trays with no date label and the two fruit cups showed sell by date of 12/23/2025; 3) A container of tartar sauce with a 08/01/2025 use by date; 4) A plastic bag with salad dated 12/18/2025; 5) A container with a soup with no resident name or date; 6) A jar of homemade chicken broth and an orange with note showing placed on 12/20/2025; 7) A container of salad with no name or date; and 8) A paper bag with half eaten pastry with no name or date.

Review of the temperature logs for the 100 and 200 Hall Refrigerators showed Refrigerator Temp 36-46 Degrees Fahrenheit.

During an interview on 01/14/2026 at 9:26 AM, Staff CC, Dietary Manager, stated nursing staff was responsible for maintaining the resident refrigerators' safe food storage.

Staff CC stated food should be thrown away after 48 hours and food should be stored at 41 F or below.

Staff CC stated the temperature log sheets used to monitor the resident refrigerators showed an acceptable range of 34-46 F, and this was inaccurate.

During an interview on 01/14/2026 at 10:26 AM, Staff A, Administrator, stated the observations of food outside of date range and temperature logs indicating inaccurate safe food temperatures did not meet expectations.

Reference WAC 388-97-1100(3), -2980

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Findings included.Review of facility licensing data, effective 06/01/2020,

Social Services Assistant, stated the facility's Social Services Director had been on maternity leave for two weeks and they were handling the qualified social worker duties until they returned.

Staff V stated they were told they would receive assistance during the social services director's leave but were unsure when this help would arrive.

Staff V stated they did not have formal education in the field of social work.

During an interview on 01/08/2026 at 2:29 PM, Staff A, Administrator, stated the facility was licensed for 130 beds.

Staff A stated the facility employed a qualified social worker to ensure residents had access to medically related social services.

Staff A said the qualified social worker should have a bachelor's degree in social services and be employed full-time.

Staff A stated the social services director has been on leave since around 12/19/2025 and would be on leave for at least two more weeks.

Staff A stated they were a qualified social worker, and a qualified social worker was available via phone or email, but they were not serving as full-time qualified social worker at this time.

Reference WAC 388-97-0960(2)(a)(b).

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Findings included.

Review of the facility document titled Infection Prevention and Control Program dated 01/21/2025 showed they followed accepted infection prevention and control standards set by the Centers for Disease Control. <Tracking/Trending>

Review of the facility provided infection control surveillance documentation for October, November and December 2025 showed infections had not been tracked to determine potential spread using a map or other tracking tool, further review showed no documented analysis of the monthly infection data to identify trends or interventions to address trends for all 3 months.

During an interview on 01/12/2026 at 12:12 PM, Staff H, Licensed Practical Nurse/Assistant Director of Nursing, acting Infection Preventionist stated it was their expectation that all new infections be identified and tracked on the infection control line list and map daily and should be analyzed monthly and implement education or changes if trends were identified. <TBP>

Review of the Aerosol/Contact precautions sign posted outside of room [ROOM NUMBER], undated, showed staff must perform hand hygiene and put on a gown, gloves, an N95 respirator and eye protection when entering the room.

Observation on 01/05/2026 at 12:32 PM showed Staff O, Registered Nurse, entered room [ROOM NUMBER] with a surgical mask and no eye protection.

Staff O Provided the resident medications and exited the room.

Review of the Enhanced Barrier Precautions sign posted outside room [ROOM NUMBER], undated showed staff must perform hand hygiene and wear a gown and gloves for all high contact activities such as dressing, Bathing, transferring, or changing linens.

Observation on 01/07/2026 at 9:13 AM showed Staff Q and another unidentified Staff enter room [ROOM NUMBER] and provide personal high contact care to the resident without wearing a required gown.

During an interview on 01/12/2026 at 12:55 PM, Staff B, Director of Nursing Services stated it was their expectation that the infection preventionist track all facility infections and map them daily and the infection surveillance data should be analyzed monthly to identify trends.

This did not happen for the months of October, November and December 2025 and should have.

Staff B stated it was their expectation that staff follow the directions on the transmission-based precautions signs posted outside of the resident rooms.

Reference WAC 388-97 -1320(1)(a)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

During an interview on 01/12/2026 at 12:06 PM, Staff H, Licensed Practical Nurse/Assistant Director of Nursing, acting infection preventionist stated it was their expectation that residents are assessed, educated and offered the pneumococcal vaccines on admission and if they consent should receive it within a week of consent.

During an interview on 01/12/2026 at 12:50 PM, Staff B, Director of Nursing Services stated it was their expectation that residents receive the VIS form and were educated on the risks and benefits when they were offered the vaccines and if the resident consented to the vaccine it should have been ordered from the pharmacy and given right away.

Staff B stated that the pneumococcal vaccines for Residents 5,19,35, 42,63 and 65 did not meet expectations.

Reference WAC 388-97 -1340(1)(2)(3)

505485 01/14/2026

Linden Grove Health Care Center 400 - 29th Street Northeast Puyallup, WA 98373

Findings included.

Review of the facility policy titled Coronavirus Disease (Covid-19) - Vaccination of Residents undated, showed each resident would be offered the Covid-19 vaccine and if the resident or their representative consents to the vaccine the facility would provide the vaccine at the facility or arrange with an outside service.

Resident 26

Review of the electronic health record (EHR) showed Resident 26 admitted to the facility on [DATE] with a diagnosis of diabetes (when the body cannot process sugars) and had consented to receive the Covid-19 vaccine on 12/16/2025. No documentation was found in the EHR of the administration of the vaccine.

Resident 19

Review of the EHR showed Resident 19 admitted to the facility on [DATE] with a diagnosis of skin infection.

The resident had consented to receive the Covid-19 vaccine on 10/26/2025. No documentation was found in the EHR of the administration of the vaccine.

During an interview on 01/12/2026 at 12:06 PM, Staff H, Licensed Practical Nurse/Assistant Director of Nursing, acting Infection Preventionist stated it was their expectation that residents are assessed, educated and offered the Covid-19 Vaccine and if they consent should receive it within a week of consent.

During an interview on 01/12/2026 at 12:50 PM, Staff B, Director of Nursing Services stated it was their expectation that resident receive the VIS form and are educated on the risks and benefits when they are offered the vaccines and if the resident consents to the vaccine it should be ordered from the pharmacy and administered as soon as available

Reference WAC 388-97 -1620(2)(b)(i)(ii)