The medication errors occurred repeatedly over two months, with nurses administering insulin when Resident 21's blood glucose levels fell below the safety thresholds set by doctors. The violations placed the resident at risk for hypoglycemia, seizures, coma and death.
Federal inspectors found the facility failed to ensure residents were free from significant medication errors during their February 28 visit. The inspection also revealed widespread infection control failures, including staff ignoring isolation protocols and allowing catheter bags to drag on floors.
Resident 21, who was cognitively intact and required daily insulin injections, had specific physician orders for when to hold the medication. For fast-acting Aspart insulin given with meals, nurses were ordered to withhold the dose if blood glucose dropped below 150. For long-acting Lantus insulin, the hold threshold was 100.
The medication administration records showed a pattern of dangerous violations throughout January and February 2025.
On January 1, nurses gave Resident 21 morning insulin when blood glucose measured 110, well below the 150 threshold. They repeated the error at lunch with a reading of 131. The same day should have triggered two medication holds.
The most alarming incident occurred January 21, when a nurse administered long-acting Lantus insulin despite a blood glucose reading of just 77. That level was 23 points below the safety threshold and approaching the range where hypoglycemic symptoms typically begin.
February brought more violations. On February 8, nurses gave both types of insulin when the resident's blood glucose measured 90, triggering two separate medication errors in one morning. On February 16, they administered fast-acting insulin with a reading of 79. Three days later, both insulin types were given with a glucose level of 92.
Staff C, the facility's Resident Care Manager, confirmed all 20 violations when questioned by inspectors on February 28. The manager acknowledged that nurses had administered insulin rather than holding it as ordered in each instance.
The errors represent a fundamental breakdown in diabetes management. Insulin lowers blood glucose levels, and giving the medication when levels are already low can trigger hypoglycemia. Severe hypoglycemia can cause confusion, seizures, loss of consciousness, and death if untreated.
Beyond medication errors, inspectors documented systematic infection control failures that put multiple residents at risk.
Two residents with urinary catheters had their drainage bags and tubing touching or dragging on floors, violating basic infection prevention standards. The Centers for Disease Control and Prevention strongly recommends that catheter bags never rest on the floor due to infection risks.
Resident 331's catheter bag was observed touching the ground during multiple visits between February 23 and 28. On February 28, a nursing assistant moved the resident from bed to wheelchair, handling the catheter bag while it touched the floor, then left without addressing the contamination.
Staff G, a licensed practical nurse, confirmed the bag should not have been touching the ground when questioned by inspectors.
Resident 39's situation was worse. Inspectors observed the person's catheter bag dragging on the hallway floor while being transported in a wheelchair. Even when enclosed in a dignity cover, the bag continued touching and dragging on surfaces as staff moved the resident through common areas.
The facility also failed to enforce Enhanced Barrier Precautions for residents with multidrug-resistant organisms. These protocols require staff to wear gowns and gloves during high-contact care activities to prevent transmission of dangerous bacteria.
Resident 331, who required Enhanced Barrier Precautions due to a urinary catheter, received care from multiple staff members who ignored gown requirements. On February 25, a licensed practical nurse entered the room to give insulin, cleaned the resident's abdomen, and administered the injection without wearing a gown.
Three days later, a nursing assistant helped move Resident 331 from bed to wheelchair, handling the person's body and medical equipment without proper protective gear. When questioned, the assistant admitted forgetting to wear a gown and acknowledged knowing the requirements.
Contact precaution protocols were equally confused. Staff gave conflicting explanations about restrictions for residents with multidrug-resistant organisms, with some believing contact precautions only applied to direct touching and others unsure about movement outside patient rooms.
Resident 39, who had tested positive for Extended-spectrum beta-lactamases and E. coli bacteria, was placed on both Enhanced Barrier Precautions and contact isolation. Despite having signs posted outside the room indicating both protocols, staff members provided contradictory information about what precautions applied outside the room.
One nursing assistant said contact precautions were "only hands on" and that Enhanced Barrier Precautions were "more hands off," demonstrating fundamental misunderstanding of infection control protocols. A licensed practical nurse said the resident could leave their room without restrictions.
The infection preventionist acknowledged the confusion, saying precautions depended on whether conditions "could safely be contained" but providing no clear guidance about when residents on contact isolation could participate in activities outside their rooms.
Wound care violations compounded the infection risks. During a February 26 observation, a licensed practical nurse performed wound care on Resident 22's stage 4 pressure ulcer using contaminated gloves.
The nurse put on gloves, used both hands to reposition the resident, then proceeded to treat the wound with the same gloves that had touched the resident's body. After completing wound care, the nurse used the contaminated gloves to reapply the resident's brief, reposition them, and adjust clothing.
When confronted about the observation, the nurse admitted knowing proper procedure required changing gloves and performing hand hygiene before touching the wound. "I knew I should have done it," the nurse told inspectors.
The violations occurred at a 120-bed facility that has faced ongoing scrutiny for care quality issues. Life Care Center of Port Orchard is part of the Life Care Centers of America chain, which operates nursing homes across multiple states.
Federal inspection records show the facility's problems extended beyond individual staff errors to systemic failures in training, oversight, and protocol enforcement. The insulin medication errors alone affected one resident over 20 separate occasions, suggesting absent or ineffective monitoring systems.
For Resident 21, the repeated insulin errors meant living with the constant risk of dangerous blood sugar drops. Each violation represented a moment when proper medication management could have prevented potentially life-threatening complications, but staff either ignored or misunderstood basic safety protocols that protect diabetic residents from harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Port Orchard from 2025-02-28 including all violations, facility responses, and corrective action plans.
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