Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Linden Grove Health Care Center during CMS and state inspections, most recent first.
The facility failed to prevent multiple resident-to-resident physical altercations despite policies prohibiting abuse. In one case, a moderately cognitively impaired resident with Alzheimer’s took food from a used tray in the dining room, and a cognitively intact resident verbally objected, leading the first resident to strike the second in the face and cause a fall. In another case, two severely cognitively impaired roommates with dementia pushed each other during a dispute over a wheelchair, resulting in one resident falling and reporting head and back impact, while the other reported pushing too hard when trying to protect her wheelchair.
A resident with a Foley catheter did not receive necessary care or monitoring, as there were no documented orders, care plans, or staff tasks addressing catheter care or securement. The resident developed severe pain and a mucosal membrane pressure injury at the catheter site, requiring hospital transfer and intervention. Facility staff confirmed that expected protocols for catheter care were not implemented.
A resident with cognitive impairment and a history of stroke and dementia, who required staff assistance for daily living, was able to leave the facility unsupervised due to failures in risk assessment, monitoring, and staff communication. The resident was later found by bystanders on a freeway ramp after a fall and was transported to the hospital, with facility staff unaware of the resident's absence until notified by the hospital. The facility's investigation revealed deficiencies in elopement risk evaluation, delayed response in searching for the resident, and lack of familiarity among reception staff with residents.
The facility failed to obtain informed consent for psychotropic medications for three residents. A resident received Zolpidem Tartrate and Escitalopram Oxalate without proper consent documentation, another was given risperidone without consent, and a third received Trazodone without verbal or written consent. Staff interviews confirmed the lack of documentation and the failure to meet expected procedures.
The facility failed to obtain necessary consent, assessment, and physician orders for the use of low beds, considered a form of physical restraint, for three residents. These residents, who were assessed as fall risks and required staff assistance, were observed in low beds without the required documentation. The Director of Nursing acknowledged this did not meet expectations, and this issue was previously cited.
The facility failed to investigate multiple allegations of abuse and neglect, including a resident left in a wheelchair for three nights, another resident's electric wheelchair removed without proper documentation, and unaddressed medication issues. Staff interviews revealed a lack of communication and failure to recognize these situations as neglect, leading to potential risks for continued abuse and diminished quality of life.
The facility failed to monitor and correctly set Low Air Loss Mattresses (LALM) for three residents, leading to a deficiency in pressure ulcer care. A resident with multiple health issues had an LALM incorrectly set at 200 lbs, despite weighing 126.8 lbs. Similar issues were found with two other residents, whose LALM settings did not match their weights. Maintenance staff set up the LALM based on estimated weight ranges, and licensed nurses were responsible for monitoring, which was not documented.
The facility did not maintain the required minimum RN coverage of eight hours daily for 60 out of 92 days. Nursing schedules for July, August, and September 2024 revealed significant gaps in RN coverage. The Staffing Coordinator admitted to the shortage of available RNs, and the DON confirmed that the facility's expectations were not met.
The facility failed to provide non-pharmacological interventions (NPI) before administering PRN pain medications to several residents, despite orders to do so. Residents with various medical conditions received pain medications without prior NPI, as documented in their medication administration records. Interviews with staff confirmed that the facility's expectations for documenting NPI were not met.
The facility's QAPI program failed to identify and address deficiencies, leading to repeated issues. Key deficiencies included failure to report abuse allegations, improper use of pressure ulcer prevention interventions, and lack of psychotropic medication consents. The QAPI committee was often unaware of these issues, resulting in unresolved deficiencies.
A facility failed to review and update the AD for a resident with dementia, missing required reviews and lacking documentation of court-appointed guardianship. Staff interviews revealed a lack of follow-up and documentation efforts, placing the resident at risk of not having an established decision maker.
A resident's personal wheelchair had armrests in disrepair, with cracked vinyl exposing uncleanable surfaces. The resident, diagnosed with cancer and depression, reported the issue, and staff confirmed the need for repair or replacement. The condition did not meet the facility's expectations.
A resident with palliative care needs was left in a power wheelchair for three nights due to missing transfer equipment, preventing proper wound care and causing distress. Despite staff being informed, the issue was not promptly addressed, leading to an allegation of neglect.
The facility failed to provide written transfer notifications to two residents or their representatives, as well as the Ombudsman program. One resident with encephalopathy and diabetes and another with heart failure and COPD were transferred to the hospital without receiving the required written notices. Staff acknowledged the oversight, admitting that only verbal notifications were given.
The facility failed to provide written bed hold notices for two residents transferred to the hospital, as required by regulations. Resident 81, with encephalopathy and diabetes, and Resident 13, with heart failure and COPD, were both transferred and readmitted without proper bed hold documentation. Staff acknowledged the oversight, citing procedural lapses.
A resident with multiple diagnoses, including anxiety and depression, was inaccurately assessed in the facility's records. The PASARR indicated a level 2 evaluation requiring special interventions, but the MDS was incorrectly coded, failing to reflect this status. Staff interviews confirmed the error in the assessment coding.
The facility failed to complete timely and accurate PASARR assessments for two residents, leading to potential risks for unidentified mental health needs. One resident's PASARR was delayed and initially inaccurate, missing serious mental illness indicators, while another resident's PASARR was completed late, not meeting the required timeline. Staff interviews confirmed these deficiencies.
The facility failed to develop comprehensive care plans for two residents, one with impaired vision and another who smoked. Despite assessments indicating these needs, the care plans lacked specific measures to address them, as confirmed by staff interviews. This oversight placed the residents at risk of unmet care needs.
The facility failed to conduct timely care planning meetings for two residents, one with multiple diagnoses including quadriplegia and another with dementia. Both residents did not recall recent care conferences, and the Social Service Director confirmed the lapse, while the Administrator was unaware of the missed meetings.
A resident was prescribed quetiapine for schizophrenia without proper documentation or diagnosis in their medical records. Despite being admitted with other conditions, there was no evidence supporting the schizophrenia diagnosis, as required by CMS and DSM-5 criteria. Facility staff were unable to provide justification for the diagnosis, highlighting a failure to meet professional standards of practice.
A resident was confined to bed due to the lack of a suitable wheelchair, preventing them from leaving their room. Additionally, two residents did not receive prescribed bowel management medications, despite not having bowel movements for several days. Staff interviews revealed that the facility's alert system for bowel protocols was not effectively utilized.
A facility failed to administer a nutritional supplement, Med Pass 2.0, as ordered for a resident at nutritional risk. Despite orders to provide the supplement when intake was less than 50%, records showed no documentation of it being given, and the resident's intake remained poor. Interviews revealed a lack of communication and follow-through among staff, leading to unmet nutritional needs.
A facility failed to provide oxygen therapy as ordered for a resident with dementia and asthma. Despite orders for oxygen at 1-2 liters per minute, observations showed the oxygen concentrator was unused, and the resident was not using oxygen. Staff inaccurately documented that the resident was receiving oxygen, with a nurse stating this was due to the resident's O2 saturation levels being above 92%. The DON confirmed that provider orders were not followed.
A resident with multiple diagnoses, including chronic pain and paraplegia, did not receive pain management as per provider's orders, affecting their participation in therapy. Despite having orders for pain medications, the facility failed to administer them consistently, and non-pharmacological interventions were not offered. Staff interviews indicated awareness of the resident's pain, but appropriate actions were not taken, leading to a deficiency in care.
A facility failed to act on a pharmacist's recommendations for a resident's medication regimen, specifically regarding Clonazepam and Zolpidem Tartrate. The pharmacist suggested reducing Clonazepam to lower fall risk and discontinuing or documenting the extended use of Zolpidem as per CMS guidelines. However, the provider declined the Clonazepam recommendation without clear rationale, and documentation for Zolpidem was incomplete. Interviews revealed no documentation of a gradual dose reduction for Zolpidem, and the Director of Nursing acknowledged the oversight.
The facility failed to conduct gradual dose reductions (GDR) and monitor side effects for psychotropic medications in several residents. A resident with multiple diagnoses did not receive a GDR or psychiatrist evaluation as required. Another resident on Risperidone did not have documented orthostatic blood pressure readings. Additionally, a resident on Zolpidem Tartrate had incomplete documentation of side effects, hours of sleep, and non-drug interventions. Staff acknowledged these documentation failures.
Two residents in an LTC facility were at risk due to inadequate monitoring and care planning. A resident with cognitive impairment and a history of elopement had a non-functional wanderguard, leading to multiple elopement incidents. Another resident with a history of falls did not have a new intervention included in their care plan, resulting in repeated falls. These deficiencies in monitoring and care planning placed the residents at risk for injury.
A facility failed to ensure proper labeling and storage of medications, as observed in one medication cart. An RN, due to a dead laptop battery, prepared medications ahead of time, labeling them with only residents' first names. Additionally, a bag with tablets was improperly labeled. The DON confirmed the practice did not meet safety standards.
A resident with multiple diagnoses, including a stroke and paralysis, did not receive dressing changes as ordered, with eight missed changes documented in December. The facility's Assistant DON confirmed that the lack of documentation indicated the changes were not completed, placing the resident at risk of unmet needs and decreased quality of life.
The facility failed to obtain necessary consents and physician orders for physical restraints and monitoring devices for several residents. Two residents had beds placed against the wall and perimeter mattresses without documented orders or consents, while two others wore Wanderguard devices without documented consents. Staff interviews revealed no formal consent form for these devices, and the Director of Nursing acknowledged recent charting system changes that may have contributed to the oversight.
The facility failed to provide eight consecutive hours of direct care supervision by an RN for 9 of 29 days reviewed and did not meet the State RN staffing requirement of 24-hour RN coverage for 29 of 29 days reviewed. The DNS acknowledged the lack of 24-hour RN coverage and mentioned that only LPNs were available to work the floor. The facility had recently hired two RNs and started using agency staff to cover LN and NAC positions, along with increasing their pay scale and revamping employee retention tactics to address the staffing issues.
Failure to Prevent Resident-to-Resident Physical Altercations
Penalty
Summary
The facility failed to protect residents’ right to be free from physical abuse in multiple resident-to-resident altercations. Facility policy dated April 2021 required policies to prohibit and prevent resident abuse, neglect, and exploitation, including prevention measures. Despite this, one incident involved a moderately cognitively impaired resident with late-onset Alzheimer’s disease taking food from a used tray in the main dining room near the end of a meal. Another cognitively intact resident told him he could not take food from trays, after which the first resident hit the second resident in the face, causing the second resident to fall to the ground. Both residents later described the event as beginning when the first resident took cornbread from a used tray and the second resident verbally intervened, leading to tempers flaring and the physical strike. In a separate incident, two severely cognitively impaired residents with Alzheimer’s disease or unspecified dementia with behavioral disturbances were involved in a physical altercation over a wheelchair in their shared room. One resident attempted to take or touch the other resident’s wheelchair, and both residents pushed each other, resulting in one resident falling to the ground and reporting she hit her head and back. Progress notes documented that the resident who fell reported being pushed down by her roommate, while the other resident reported pushing her roommate away from the wheelchair and accidentally pushing too hard, causing the fall. Both residents later did not remember the incident. These events occurred despite the facility’s stated policies to prevent abuse and resident-to-resident altercations.
Failure to Provide Foley Catheter Care and Monitoring Resulting in Pressure Injury
Penalty
Summary
The facility failed to provide necessary care and monitoring for a Foley catheter, resulting in an avoidable pressure injury at the catheter insertion site for one resident. Upon readmission, the resident had a Foley catheter in place due to obstructive uropathy and was cognitively intact. Throughout the resident's stay, there were no documented physician orders, care plans, eTAR entries, Point of Care tasks, or Kardex guidance related to Foley catheter care, monitoring, or securement. Progress notes and assessments also lacked documentation of catheter care or monitoring. The resident experienced severe, unrelieved pain at the catheter site, which was not alleviated by prescribed interventions, and exhibited signs of distress such as anxiousness, restlessness, and verbalizing discomfort. The resident was eventually transferred to the hospital, where it was noted that the catheter and surrounding area were unclean, and a significant meatal erosion was identified at the insertion site. Hospital records indicated that exchanging the Foley catheter resolved the resident's pain, and a mucosal membrane pressure injury (MMPI) was diagnosed. Interviews with facility staff confirmed that expected protocols for Foley catheter care and monitoring were not in place or followed for this resident.
Failure to Prevent Elopement and Provide Adequate Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to accurately assess, identify, monitor, and supervise a resident at risk for elopement, resulting in the resident leaving the facility unsupervised and sustaining harm. The resident, who had a history of stroke, dementia, and encephalopathy, was documented as requiring staff assistance for activities of daily living and was noted in the care plan to be at risk for falls and injury due to cognitive loss and lack of safety awareness. Despite these documented risks, the resident was able to exit the facility without staff knowledge or intervention. On the day of the incident, nursing notes indicated that the resident had previously expressed a desire to leave and had shown signs of confusion and attempts to leave the facility. The resident was last checked on in their room in the early afternoon, and when staff later noticed the resident was missing, there was a delay in initiating a search. Staff were unclear about which residents were allowed to leave and did not immediately begin looking for the missing resident. Additionally, staff in the reception area did not notice the resident leaving the building. The resident was subsequently found by bystanders on a freeway ramp after having fallen and sustained injuries, including abrasions and bruising. Emergency services were called, and the resident was transported to the hospital, where it was determined that facility staff were not aware the resident was missing until contacted by the hospital. The facility's own investigation identified issues with the accuracy of the elopement risk assessment, delays in searching for the resident, and lack of familiarity among reception staff with the residents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of psychotropic medications for three residents, which is a requirement to ensure residents or their legal representatives are fully informed about their treatment. Resident 92 was prescribed Zolpidem Tartrate for insomnia and Escitalopram Oxalate for depression, but the consent for Zolpidem Tartrate lacked documentation of the medication's frequency, and no consent was found for Escitalopram Oxalate. Staff interviews confirmed the absence of proper documentation and acknowledged that the expected procedures were not followed. Resident 87 was prescribed risperidone, an antipsychotic medication, without any consent documentation on file. Similarly, Resident 2 was administered Trazodone for insomnia without obtaining verbal or written consent. Staff interviews revealed that the necessary consents were not located, and the expectation was that consents should be obtained prior to medication administration. These oversights placed residents at risk of not being fully informed about their medication use, potential side effects, and the ability to make informed decisions about their care.
Failure to Obtain Consent and Orders for Low Bed Use
Penalty
Summary
The facility failed to obtain a provider's order, assessment, and consent for the use of low beds for three residents, which is considered a form of physical restraint. The facility's policy requires that physical restraints, including low beds, should only be used upon the written order of a physician and after obtaining consent from the resident or their representative. However, for Residents 86, 74, and 89, there was no documentation of consent, order, or assessment for the use of low beds, which were observed during the survey. Resident 86, who was admitted with conditions such as intracranial hemorrhage, anxiety, depression, and aphasia, was assessed as a fall risk and required staff assistance for mobility. Despite this, there was no documentation supporting the use of a low bed. Similarly, Resident 74, diagnosed with dementia, depression, and osteopenia, and Resident 89, diagnosed with dementia, anxiety, and receiving palliative care, were also observed in low beds without the necessary documentation. The Director of Nursing Services acknowledged that the lack of consent, assessment, and order did not meet the facility's expectations. This deficiency was previously cited in a Statement of Deficiencies.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and investigate allegations of abuse and neglect for several residents, leading to potential risks for continued abuse and diminished quality of life. Resident 78, who was dependent on staff for transfers, reported being left in a power wheelchair for three nights due to missing equipment. Despite the resident's grievance and staff awareness, no investigation was initiated, and the incident was not logged in the facility's records. Staff interviews revealed a lack of communication and failure to recognize the situation as neglect. Resident 48 experienced a safety incident involving their electric wheelchair, which was removed after being seen in the roadway. Although staff were aware of the incident, it was not documented in the incident log, and no investigation was conducted. Similarly, Resident 77 reported a resident-to-resident altercation that was not logged or investigated, despite staff acknowledging the need for such actions. The lack of documentation and follow-up on these incidents highlights a systemic issue in addressing and investigating potential neglect and abuse. Other residents, such as Resident 360 and Resident 66, also reported issues with medication administration and being left uncovered, respectively. These incidents were not logged or investigated, indicating a broader failure to adhere to facility policies and state regulations. The facility's inaction in these cases demonstrates a significant deficiency in ensuring resident safety and addressing grievances appropriately.
Failure to Monitor and Set Low Air Loss Mattress Correctly
Penalty
Summary
The facility failed to ensure that the ordered intervention of a Low Air Loss Mattress (LALM) was properly monitored and used as directed for three residents, leading to a deficiency in pressure ulcer care. Resident 73, who had diagnoses including heart and lung disease, dementia, and malnutrition, was dependent on staff for all activities of daily living and had pressure ulcers on the buttocks and heels. Despite the care plan specifying the use of an air mattress for pressure reduction, the LALM was incorrectly set at 200 lbs, while the resident's actual weight was 126.8 lbs. Staff interviews revealed that the maintenance department set up the LALM based on an estimated weight range, and licensed nurses were responsible for monitoring the settings, which were not documented in the electronic health record. Further investigation showed similar issues with Residents 83 and 18, whose LALM settings were also incorrect based on their documented weights. Resident 83, weighing 83 lbs, had the LALM set at 200 lbs, and Resident 18, weighing 90 lbs, had the LALM set at 400 lbs. The Assistant Director of Nursing stated that the expectation was for maintenance staff to set up the LALM based on residents' weights and for licensed nurses to ensure the settings were correct. This failure to implement the care plan as ordered prevented the facility from promoting wound healing and preventing further decline in the residents' conditions.
Failure to Maintain Minimum RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for a minimum of eight hours each day, as required, for 60 out of 92 days reviewed for staffing. Specifically, the nursing schedules for July, August, and September 2024 showed that there was no RN scheduled for 23, 19, and 18 days, respectively. This deficiency was identified through observation, interviews, and record reviews. During interviews, the Staffing Coordinator acknowledged the shortage of available RNs and the Director of Nursing Services confirmed that the lack of daily RN coverage did not meet the facility's expectations.
Failure to Provide Non-Pharmacological Interventions Before PRN Pain Medications
Penalty
Summary
The facility failed to provide non-pharmacological interventions (NPI) prior to administering as-needed (PRN) pain medications for six of eight sampled residents. This deficiency was identified through interviews and record reviews, revealing that residents were at risk of taking unnecessary medications, experiencing avoidable side effects, and having a diminished quality of life. The residents involved had various medical conditions, including palliative care, osteomyelitis, diabetes, heart and lung disease, fibromyalgia, quadriplegia, radiculopathy, anxiety, depression, dementia, atrial fibrillation, insomnia, kidney disease, and Crohn's disease. For Resident 78, the electronic health record showed nearly daily administration of PRN narcotic pain medication without prior NPI in December 2024 and January 2025. Similarly, Resident 48's medication administration record (MAR) for January 2025 lacked consistent documentation of NPI despite orders to attempt such interventions before administering oxycodone and acetaminophen. Resident 94's MAR also showed multiple entries of administered pain medications without consistent documentation of NPI, despite orders to document such interventions and their effectiveness. Resident 92 received narcotic pain medication 77 times in January 2025 without documented NPI, contrary to the provider's orders. Resident 360's MAR showed no order for NPI, yet the resident received acetaminophen and narcotic medications multiple times. Lastly, Resident 87's December 2024 MAR showed no documented NPI before administering acetaminophen. Interviews with staff, including the Director of Nursing Services and Assistant Director of Nursing, confirmed that the facility's expectations for documenting NPI prior to PRN medication administration were not met.
Repeated Deficiencies Due to Ineffective QAPI Program
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively identified and addressed deficiencies, leading to repeated issues and a pattern of deficiencies. During the Long Term Care survey conducted on January 29, 2025, it was found that the facility did not identify or address several areas of concern, including the failure to report and investigate allegations of abuse or neglect for six out of seven sampled residents. Additionally, the facility did not ensure the proper use and monitoring of ordered interventions, such as the Low Air Loss Mattress, for the prevention of pressure ulcers in three out of seven residents. The facility also demonstrated ineffective plans of correction for sustaining compliance in various areas, resulting in repeated deficiencies. For instance, the facility failed to complete and maintain psychotropic medication consents before administering these medications to three out of five sampled residents. Furthermore, the facility did not periodically review residents' advanced directives or maintain court-appointed guardianship documentation, affecting one out of two sampled residents. These issues were not brought to the attention of the QAPI committee, indicating a lack of awareness and oversight. Additional deficiencies included the failure to provide a safe, sanitary, and homelike environment, obtain necessary consents for the use of physical restraints, and provide written notifications for transfers or bed hold policies. The facility also failed to accurately assess residents' conditions, develop comprehensive care plans, and ensure professional standards of practice were met. Despite some awareness of certain issues, such as staffing shortages, the QAPI committee was generally unaware of many concerns, leading to repeated citations and unresolved deficiencies.
Failure to Review Advanced Directive and Obtain Guardianship Documentation
Penalty
Summary
The facility failed to periodically review and update the advanced directive (AD) for Resident 77, who was admitted with diagnoses including dementia, depression, and osteoarthritis. Despite being unable to sign AD documentation due to cognitive issues, the facility did not conduct the required reviews in August and November 2024. This oversight was acknowledged by Staff F, who confirmed that the reviews were missed. Additionally, there was a lack of documentation regarding the court-appointed guardianship, which was supposed to be obtained and maintained in the resident's medical records. Interviews with facility staff revealed that there was a breakdown in communication and follow-up regarding the guardianship documentation. Staff D, the Business Office Manager, admitted that they did not follow up with the resident's family to obtain the necessary paperwork, nor did they document attempts to do so. The Administrator confirmed that ADs should be reviewed upon admission, quarterly, and as needed, and that Social Services were responsible for obtaining the AD. This failure placed Resident 77 at risk of not having an established decision maker and a diminished quality of life.
Deficient Wheelchair Maintenance for Resident
Penalty
Summary
The facility failed to provide a safe, sanitary, and homelike environment for Resident 62, who was reviewed for environmental conditions. Resident 62, who had diagnoses including cancer and depression, was observed using a personal wheelchair with both armrests in disrepair. The armrests had multiple cracked areas in the vinyl, exposing beige material underneath, creating an uncleanable surface. During interviews, Resident 62 expressed that the armrests were rough to the touch and that staff should have noticed the need for repair or replacement. Staff E, an LPN, confirmed the poor condition of the armrests and acknowledged the need for maintenance and physical therapy intervention. Staff B, the Director of Nursing Services, also stated that the condition of the wheelchair armrests did not meet expectations.
Neglect Due to Missing Transfer Equipment
Penalty
Summary
The facility failed to ensure a resident was free from neglect, as evidenced by the incident involving Resident 78. The resident, who was admitted with diagnoses including palliative care, osteomyelitis, and diabetes, was dependent on staff for transfers in and out of bed using a mechanical lift. However, due to the facility's inability to locate a necessary piece of equipment, Resident 78 was left in their power wheelchair for three consecutive nights, preventing proper transfer and wound care. This situation caused distress to the resident, who subsequently took measures to prevent a recurrence by keeping the equipment with them in bed. Interviews with staff revealed a breakdown in communication and response to the resident's needs. Staff P, a CNA, reported the missing equipment to Staff N, an LPN, who was on vacation at the time. Upon return, Staff N checked the resident's wounds and located the missing equipment. Despite being informed of the situation, Staff B, the DNS, was unaware that the resident had slept in their wheelchair for three nights. Additionally, the resident filed a grievance form alleging neglect, which was reported to the DNS by Staff F from Social Services. The facility's policy requires all allegations of neglect to be reported and investigated, but this was not adequately followed in this case.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written notification of the reason for hospital transfer to two residents, Resident 81 and Resident 13, or their representatives, as well as the Washington State Long-Term Care Ombudsman program. Resident 81, who was admitted with encephalopathy and diabetes, was hospitalized and readmitted without receiving a written notice of transfer. Staff C, the Assistant Director of Nursing, acknowledged that the resident or their representative did not receive the required written notice, which should have been provided upon transfer or sent via certified mail. Similarly, Resident 13, who had diagnoses including heart failure and chronic obstructive pulmonary disease, was transferred to the hospital and readmitted without receiving a written notification of the transfer. Staff E, an LPN, admitted to providing only verbal notification, while Staff B, the Director of Nursing Services, could not confirm if a written notification was sent. Additionally, Staff F from Social Services confirmed that the Ombudsman program was not notified in writing about Resident 13's transfer, which was a requirement.
Failure to Provide Bed Hold Notices for Hospitalized Residents
Penalty
Summary
The facility failed to provide written bed hold notices at the time of transfer to the hospital for two residents, which is a requirement under WAC 388-97-0120 (4). Resident 81, who had diagnoses including encephalopathy and diabetes, was hospitalized and readmitted without any documentation or progress notes related to a bed hold for the hospitalization. Staff D, the Business Office Manager, acknowledged the oversight, attributing it to the transfer occurring over the weekend. Staff C, the Assistant Director of Nursing, confirmed that a bed hold packet should have been offered to Resident 81, who was alert and oriented. Similarly, Resident 13, with diagnoses including heart failure and chronic obstructive pulmonary disease, was transferred to the hospital and later readmitted without a bed hold form documented in their electronic health record. Staff D confirmed the absence of the necessary documentation, and Staff B, the Director of Nursing Services, stated that bed holds should be offered to all residents upon hospital transfer. The lack of bed hold documentation for both residents indicates a failure in the facility's process to ensure residents are informed of their rights regarding bed holds during hospitalizations.
Inaccurate PASARR Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess the status of a resident, identified as Resident 41, in relation to the Pre-Admission Screening and Resident Review (PASARR), a mental health screening tool. Resident 41 was admitted with diagnoses including anxiety, chronic obstructive pulmonary disease, depression, and a personality disorder, and was capable of communicating needs. The PASARR, dated May 7, 2020, indicated that Resident 41 had a level 2 evaluation and required special interventions and follow-up by a provider. However, the minimum data set assessment (MDS) dated December 2, 2024, incorrectly coded Resident 41 as not having a level 2 PASRR and not having a serious mental illness. During interviews, both the Social Service Director and the Administrator acknowledged the coding error in the MDS, confirming that it should have reflected a level 2 PASARR.
Failure to Timely and Accurately Complete PASARR Assessments
Penalty
Summary
The facility failed to ensure timely and accurate completion of Pre-Admission Screening and Resident Review (PASARR) assessments for two residents, which placed them at risk for unidentified mental health care needs. Resident 92 was admitted with diagnoses of depression and insomnia and was receiving antianxiety, antidepressant, and hypnotic medications. However, the initial PASARR completed by the hospital case manager did not indicate any serious mental illness (SMI) indicators, and a level 2 evaluation was not conducted. A subsequent PASARR completed by the facility's Social Services Director later identified SMI indicators, but the referral for a level 2 evaluation was delayed. Staff interviews confirmed the inaccuracies and untimeliness of the PASARR process for Resident 92. Similarly, Resident 360 was admitted with a broken left upper thigh bone and kidney disease, and the PASARR was completed one day after admission, failing to meet the requirement for completion prior to or upon admission. The PASARR did not indicate any SMI indicators, and no level 1 PASARR was completed at the appropriate time. Staff interviews acknowledged the delay in completing the PASARR for Resident 360, which did not meet the facility's expectations for timely assessments.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their specific care needs. Resident 39, who was admitted with diagnoses including heart failure, diabetes, and anxiety disorder, was identified as having impaired vision without corrective lenses according to the annual minimum data set assessment. Despite this, the resident's care plan did not include any measures to address the impaired vision, as confirmed by both the MDS Nurse and the Director of Nursing Services during interviews. Similarly, Resident 84, admitted with anemia and anxiety disorder, was found to be a smoker according to the facility's Resident Smoker List and a smoking evaluation. However, the resident's care plan did not include any provisions for smoking, such as monitoring for ashes or burn holes, which was acknowledged as an oversight by a Licensed Practical Nurse and the Director of Nursing Services. These omissions in care planning placed the residents at risk of unmet care needs and potential negative outcomes.
Failure to Conduct Timely Care Planning Meetings
Penalty
Summary
The facility failed to conduct timely care planning meetings for two residents, which is a requirement to ensure that care is provided according to the residents' needs. Resident 48, who was readmitted with multiple diagnoses including heart and lung disease, fibromyalgia, quadriplegia, and depression, did not have a care conference since May 10, 2023, despite the expectation for quarterly meetings. The resident was dependent on staff for activities of daily living and was able to communicate their needs, yet they did not recall having a recent care conference. Similarly, Resident 77, who was admitted with diagnoses including dementia, depression, and osteoarthritis, also did not have a care conference since February 12, 2024. This resident was also able to communicate their needs but did not recall attending a care conference. The Social Service Director confirmed the lapse in care conferences for both residents, and the Administrator was unaware of the missed or late conferences, despite the facility's expectation for quarterly meetings.
Inappropriate Diagnosis and Medication Use for a Resident
Penalty
Summary
The facility failed to meet professional standards of practice in diagnosing a resident with mental health disorders, specifically regarding the use of unnecessary medications. Resident 2, who was admitted with diagnoses including diabetes, heart failure, depression, and suicidal ideation, was prescribed quetiapine for schizophrenia. However, there was no documentation or diagnosis of schizophrenia in Resident 2's medical records. The admitting physician's note mentioned schizophrenia, but this was not supported by any evidence or assessment in accordance with DSM-5 criteria, as required by CMS and the State Operations Manual. Interviews with facility staff revealed a lack of supporting documentation for the schizophrenia diagnosis. Staff R, the Resident Care Manager, and Staff B, the Director of Nursing Services, were unable to provide evidence or documentation to justify the diagnosis. The pharmacy consultation report highlighted the requirement for a qualified practitioner to diagnose schizophrenia using evidence-based criteria, which was not adhered to in this case. This oversight placed Resident 2 at risk for unmet needs and complications due to the inappropriate use of psychoactive medication.
Deficiencies in Mobility and Bowel Management
Penalty
Summary
The facility failed to provide a suitable mobility device for Resident 4, who was admitted with diagnoses including malignant melanoma, malnutrition, depression, and diabetes. Observations revealed that Resident 4 was confined to bed without a wheelchair that matched their height, preventing them from leaving their room and interacting with other residents. Interviews with Resident 4 and staff confirmed the absence of an appropriate wheelchair, which did not meet the facility's expectations for resident mobility. Additionally, the facility did not implement a bowel program for Residents 24 and 108, both of whom had orders for constipation management. Resident 24 experienced multiple days without a bowel movement, and the prescribed bowel medications were not administered according to the provider's orders. Similarly, Resident 108 did not receive the necessary bowel medications despite not having a bowel movement for several days. Interviews with staff indicated that the facility's system was supposed to alert nurses to initiate the bowel protocol, but this was not effectively carried out, leading to unmet needs for these residents.
Failure to Administer Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to administer the Registered Dietician's (RD) recommendations for Resident 73, who was at nutritional risk due to poor food and fluid intake. Despite having an order for Med Pass 2.0, a fortified nutritional shake, to be administered when the resident's intake was less than 50%, the medication administration records for December 2024 and January 2025 showed no documentation of the supplement being given. The resident's electronic health record (EHR) indicated multiple instances of eating less than 25-50% of meals, yet there was no documentation of Med Pass 2.0 being offered or refused. Interviews with facility staff revealed a lack of communication and follow-through on the dietary plan. The Licensed Practical Nurse (LPN) and Assistant Director of Nursing (ADON) stated that the expectation was for the Certified Nurse Aide (CNA) to inform the LPN of poor intake, who would then administer the supplement. However, this process was not followed, as evidenced by the lack of documentation and continued poor dietary intake. The RD reiterated the expectation for the LPN to administer and document the supplement as ordered, highlighting a breakdown in the facility's protocol for addressing the resident's nutritional needs.
Failure to Administer Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with provider orders for Resident 59, who was admitted with diagnoses including dementia and asthma. The provider orders specified that Resident 59 should receive oxygen therapy at 1-2 liters per minute via nasal cannula during both day and night shifts. However, observations on two consecutive days revealed that the oxygen concentrator was unused, and Resident 59 was not wearing a nasal cannula or using oxygen. Despite this, the Medication Administration Record indicated that staff had signed off daily, confirming that Resident 59 was utilizing oxygen as ordered. During interviews, Resident 59 stated they had not used oxygen since admission, and a registered nurse admitted to signing off on the oxygen administration because the resident's O2 saturation levels were consistently above 92%. The Director of Nursing acknowledged that the expectation was for provider orders to be followed, and staff should not have signed off if the resident was not using the oxygen.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide pain management as per the provider's orders for a resident, identified as Resident 24, which affected their ability to participate in physical therapy services. Resident 24, who was admitted with multiple diagnoses including multiple sclerosis, chronic pain, and paraplegia, had orders for various pain medications such as a fentanyl patch, oxycodone, and morphine sulfate. Despite these orders, the facility did not administer pain medication for 12 out of 14 instances where the resident refused restorative services due to pain. Additionally, non-pharmacological interventions were not offered during these refusals. The resident's electronic health record showed the last pain assessment was conducted several months prior, and the medication administration records indicated a lack of pain management for numerous occurrences of moderate to severe pain. Interviews with staff revealed that while they were aware of the resident's pain, appropriate measures were not consistently taken to address it. The resident expressed that their pain medications were not effective enough, and they often had to endure pain during therapy sessions. This deficiency in pain management placed the resident at risk of decreased mobility and a diminished quality of life.
Failure to Act on Pharmacist's Recommendations for Medication Management
Penalty
Summary
The facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations for Resident 92, who was reviewed for unnecessary medication use. Resident 92 had diagnoses of depression, anxiety disorder, and insomnia and was prescribed Clonazepam for anxiety and Zolpidem Tartrate for insomnia. The pharmacist recommended reducing Clonazepam to minimize fall risk, but the provider declined without a clear rationale. Additionally, the pharmacist suggested discontinuing or documenting the extended use of Zolpidem, as required by CMS guidelines, but the documentation was incomplete and lacked clarity. Interviews with facility staff revealed that there was no documentation of a gradual dose reduction (GDR) for Zolpidem, and the provider's notes did not address the pharmacy's recommendations for Clonazepam. The Director of Nursing Services acknowledged the lack of documentation and the failure to clarify the rationale for not following the pharmacist's recommendations. This oversight placed Resident 92 at risk for adverse side effects and did not meet the facility's expectations for medication management.
Failure to Conduct GDR and Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to conduct gradual dose reductions (GDR) and monitor for side effects related to the use of psychotropic medications for several residents. Resident 94, who was admitted with multiple diagnoses including heart disease, stroke, dementia, anxiety, and depression, was prescribed Clonazepam and Duloxetine. Despite the care plan indicating the need for GDR and a psychiatrist evaluation, no GDR was conducted, and no evaluation was performed since the resident's admission. The Assistant Director of Nursing acknowledged that behavioral health services were not resumed after the resident graduated from hospice care, which should have included GDRs. For Resident 87, who was admitted with dementia and required moderate assistance, the facility failed to document orthostatic blood pressure readings as required for residents receiving antipsychotic medication, specifically Risperidone. The Director of Nursing Services confirmed that the expectation was for staff to obtain and document these readings, which was not done. Resident 92, who had diagnoses including atrial fibrillation, high blood pressure, and insomnia, was prescribed Zolpidem Tartrate for severe intermittent insomnia. The facility failed to document side effects, hours of sleep, and non-drug interventions as required. The Licensed Practical Nurse and Director of Nursing Services both acknowledged that the documentation did not meet expectations, as side effects were not specified, and non-pharmacological interventions were not properly recorded.
Failure to Monitor Wanderguard and Update Care Plan Leads to Resident Risks
Penalty
Summary
The facility failed to ensure that risk factors were consistently monitored and addressed to minimize the risk for accident hazards for two residents. Resident 94, who had significant cognitive impairment and a history of elopement, was not adequately monitored with a functional wanderguard device. Despite having a care plan that required the wanderguard to be checked every shift, there were multiple instances where the checks were not documented, and the device was found to be non-functional during testing. This lack of consistent monitoring and testing led to three separate elopement incidents, where the resident was able to leave the facility without staff knowledge. Resident 86, who had a history of falls and was unable to communicate their needs, experienced multiple falls within the facility. After a fall on December 22, 2024, a new intervention was identified to assist the resident to bed after evening medications. However, this intervention was not included in the resident's care plan, and the resident experienced another fall in the dining room. The failure to update the care plan with the new intervention contributed to the repeated fall incident. The deficiencies in monitoring and updating care plans for these residents placed them at risk for potential injury and negative outcomes. The facility's policies and procedures were not consistently followed, leading to lapses in care and supervision for residents with known risks for elopement and falls.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure medications were properly labeled and stored in accordance with accepted professional standards, as observed in one of the four medication carts reviewed. During an observation, a Registered Nurse (RN), identified as Staff C, was seen with multiple clear plastic medication cups containing various pills on top of a medication cart. Each cup had a second plastic cup on top and was labeled with handwritten first names of residents, without any other identifiers. Staff C admitted to preparing the medications ahead of time due to a dead laptop battery, which was not in line with their training or safe medication administration practices. Additionally, a small clear plastic bag containing two white tablets was found in the top drawer of the medication cart, labeled with a single resident's first name. Staff C explained that the medication was meant for a resident who was supposed to take it during dialysis but did not eat, so it was returned. The Director of Nurses, Staff B, confirmed that Staff C was aware of the improper practice and acknowledged that it did not meet nursing expectations for safe medication administration, representing a significant safety risk to residents.
Failure to Complete Dressing Changes as Ordered
Penalty
Summary
The facility failed to ensure that dressing changes were completed as ordered for a resident with multiple diagnoses, including high blood pressure, a stroke, and one-sided paralysis. The resident was alert, non-verbal, and required substantial assistance with activities of daily living. An order dated 12/20/2024 specified that wound care and dressing changes to one of the resident's feet were to be done twice daily at 7:00 AM and 5:00 PM. However, the Treatment Administration Record for December 2024 showed that there were eight missed dressing changes out of 23 opportunities, with blanks or spaces without documentation for several 5:00 PM and 7:00 AM dressing changes. Staff D, a Registered Nurse and the Assistant Director of Nursing, confirmed that if a dressing change was not done, nursing staff should document the reason, such as the resident being unavailable or refusing the care. Upon reviewing the Treatment Administration Record, Staff D acknowledged that the lack of documentation indicated the dressings were not changed on the dates with blanks, and there should have been additional documentation. This failure placed residents at risk of unmet needs, decline in status, and decreased quality of life.
Lack of Consents and Orders for Restraints and Monitoring Devices
Penalty
Summary
The facility failed to obtain necessary consents and physician orders for the use of physical restraints and monitoring devices for several residents. Specifically, two residents were observed with beds placed against the wall and perimeter mattresses without documented physician orders or consents. These residents were cognitively impaired and required substantial assistance with activities of daily living, indicating a high level of dependency on staff for their care. The absence of documented consents and physician orders for these interventions suggests a lack of adherence to the facility's policy on the use of restraints, which mandates written orders and consents. Additionally, two other residents were found to be wearing Wanderguard devices without documented consents in their electronic health records. Staff interviews revealed that there was no formal consent form for such devices, and attempts to locate documentation of consent in progress notes were unsuccessful. The Director of Nursing Services acknowledged the absence of a formal consent form and mentioned recent changes to the facility's charting system, which may have contributed to the oversight. This lack of documentation and formal consent process placed residents at risk for injury and diminished quality of life.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of direct care supervision by a Registered Nurse (RN) for 9 of 29 days reviewed and did not meet the State RN staffing requirement of 24-hour RN coverage for 29 of 29 days reviewed. This deficiency was identified through interviews and record reviews. The daily nursing staff forms for May 2024 showed no RN coverage on specific dates and only 8-hour RN coverage on the remaining days. The Director of Nursing Services (DNS) acknowledged the lack of 24-hour RN coverage and mentioned that only Licensed Practical Nurses (LPNs) were available to work the floor. The facility had recently hired two RNs and started using agency staff to cover Licensed Nurse (LN) and Nursing Assistant Certified (NAC) positions, along with increasing their pay scale and revamping employee retention tactics to address the staffing issues.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 598 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Puyallup
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rainier Rehabilitation | 1.6 mi | — | 0 | 0 |
| Life Care Center Of Puyallup | 2 mi | — | 22 | 0 |
| Puyallup Post Acute | 2.5 mi | — | 36 | 0 |
| Life Care Center Of South Hill | 2.5 mi | — | 18 | 1 |
| Canterbury House | 6.4 mi | — | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Linden Grove Health Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.