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Health Inspection

Life Care Center Of Port Orchard

February 28, 2025 · Port Orchard, WA · 2031 Pottery Avenue
Citations 2
CMS Rating 5/5
Beds 125
Provider ID 505210
Healthcare Facility
Life Care Center Of Port Orchard
Port Orchard, WA  ·  View full profile →
Inspection Summary

LIFE CARE CENTER OF PORT ORCHARD in PORT ORCHARD, WA — inspection on February 28, 2025.

Found 2 citations. Severity: Standard violations.

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

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Inspection Findings

FF656
TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37044 Few insulin administration were free of significant medication errors. The failure to administer insulin in affected

Findings included .

Resident 21 admitted to the facility on [DATE].

Review of 11/21/2025 Annual Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had a diagnosis of diabetes (a condition where the body cannot use insulin correctly and glucose builds up in the blood), and required insulin injections on seven of seven days during the assessment period.

Review of the electronic health record showed Resident 21 had the following insulin orders:

a) A 02/08/2025 order for Aspart insulin (fast acting), with meals.

Hold for a BG less than 150.

b) A 11/14/2024 order for Aspart insulin sliding scale coverage three times a day.

c) A 02/07/2025 order for Lantus insulin (long acting), 11 units every morning and 18 units every evening.

Hold if BG is less than 100.

Review of the January and February 2025 Medication Administration Records showed on the following date(s)/time(s), facility nurses failed to hold Resident 21's insulin for BGs levels below than the physician ordered parameters for administration.

January 2025

a) Aspart insulin with meals, hold for BG less than 150.

01/01/2025 8:00 AM, BG= 110; insulin administered.

01/01/2025 12:00 PM, BG= 131; insulin administered.

01/12/2025 5:00 PM, BG= 134; insulin administered.

01/26/2025 8:00 AM, BG= 136; insulin administered.

01/27/2025 8:00 AM, BG= 131; insulin administered.

01/29/2025 8:00 AM, BG= 122; insulin administered.

b) Lantus insulin, hold for BG less than 100.

505210

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 505210 B.

Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

Findings included .

Review of the facility policy titled, LCC [Life Care Center] Port Orchard Bowel Protocol, undated, showed the following order of medications to be given:

1.

Milk of Magnesia (helps stimulate a bowel movement) to be given after 72 hours/on day four of no bowel movement

2.

Bisacodyl (helps stimulate a bowel movement) to be given after no bowel movement on day five

3.

Fleet Enema (helps stimulate a bowel movement) to be given after no bowel movement on day six

1) Resident 59 was admitted to the facility on [DATE] with a diagnosis of constipation.

The Admission Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 59 had severe cognitive impairment.

Review of Resident 59's orders showed three medications ordered for no bowel movement:

1.

Milk of Magnesia (for day four of no bowel movement)

2.

Bisacodyl (for day five of no bowel movement)

3.

Fleet Enema (for day six of no bowel movement)

Review of Resident 59's bowel record, from 01/28/2025 to 02/25/2025, showed that they did not have a bowel movement recorded from 02/05/2025 to 02/11/2025 (seven days).

Review of the Electronic Health Record (EHR) showed no documentation of interventions for bowel protocol/orders from 02/05/2025 to 02/11/2025.

During an interview on 02/27/2025 at 4:40 PM, Staff C, Resident Care Manager (RCM), confirmed that Resident 59 did not have a bowel movement from 02/05/2025 to 02/11/2025.

Staff C said staff should have documented that Resident 59 had refused the bowel protocol and have documented that they did a bowel assessment.

505210

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 505210 B.

Wing 02/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Port Orchard 2031 Pottery Avenue Port Orchard, WA 98366

Frequently Asked Questions

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


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