Cottesmore of Life Care: Blood Thinner Errors - WA
Resident 2 never received a scheduled dose of Warfarin on August 7, despite having a doctor's order for the blood thinner to treat atrial fibrillation. The medication was supposed to be administered at 5:00 PM that Thursday, but staff had discontinued the order at 11:59 AM the same day.
The confusion stemmed from overlapping medication orders. Electronic health records show the provider ordered Warfarin on August 4 to start August 7, but the computer system scheduled the first dose for the following Thursday instead. Meanwhile, another Warfarin order for different days of the week had been discontinued August 7.
Staff C, a registered care manager, told inspectors on August 18 that Resident 2 "should have received the Warfarin on 08/07/2025." The staff member acknowledged the medication was also held the following day.
A second resident faced an even longer gap in treatment. Resident 1 missed five consecutive doses of Warfarin between August 13 and August 17 because the prescription order was "placed incorrectly into the eMAR," according to Director of Nursing Services Staff A.
The electronic medication administration record is the digital system nursing homes use to track when residents receive their prescribed drugs.
Resident 3 experienced a different but equally serious error. Staff discontinued the resident's Rivaroxaban order by mistake, cutting off the daily blood thinner entirely. Staff A told inspectors "the Rivaroxaban order should not have been discontinued, and Resident 3 should have continued to receive it daily."
The medication errors came to light only after Staff B reported a discrepancy in Resident 1's Warfarin order to the nursing director. Staff A said she "immediately did an audit for all anticoagulants to ensure accuracy" after learning of the problem.
That audit revealed the scope of the medication failures across multiple residents.
Both Warfarin and Rivaroxaban are anticoagulants prescribed to prevent blood clots and strokes in patients with heart conditions like atrial fibrillation. Missing doses can increase the risk of dangerous clots forming, particularly in elderly patients with existing cardiovascular problems.
The inspection found the facility violated state regulations requiring proper medication administration. Washington state rules mandate that nursing homes ensure residents receive medications as prescribed by their physicians.
When inspectors asked Staff A about policies for reconciling medication orders, she said she "was not aware of a policy for order reconciliation." Such policies are designed to prevent exactly the kind of errors that affected these three residents.
The medication mistakes occurred despite electronic systems designed to prevent such errors. The eMAR technology is supposed to provide clear scheduling and tracking of when residents receive their prescribed medications.
Instead, the technology appeared to contribute to the confusion. The computer system's interpretation of the Thursday-only Warfarin order for Resident 2 differed from the doctor's intent, scheduling the first dose a week later than prescribed.
For Resident 1, the incorrect entry into the electronic system meant five days passed without the prescribed anticoagulant. Staff A's immediate audit after discovering the first error suggests the facility lacked systematic checks to catch such problems before residents were harmed.
The inspection occurred August 18 in response to a complaint, though the report does not specify what prompted the initial concern. State inspectors classified the violations as causing "actual harm" to residents.
All three residents affected were taking anticoagulants for serious cardiovascular conditions where consistent medication timing is critical for preventing life-threatening complications. The gaps in treatment lasted from one day for Resident 2 to five consecutive days for Resident 1.
The facility's lack of order reconciliation policies meant staff had no systematic way to catch such errors before residents missed critical medications. Staff A's surprise audit only occurred after problems had already affected multiple residents over several days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cottesmore of Life Care from 2025-08-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
COTTESMORE OF LIFE CARE in GIG HARBOR, WA was cited for violations during a health inspection on August 18, 2025.
Resident 2 never received a scheduled dose of Warfarin on August 7, despite having a doctor's order for the blood thinner to treat atrial fibrillation.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.