Crown Park Rehab: Missed Blood Tests Led to Stroke - NY
The resident at Crown Park Rehabilitation and Nursing Center had a mechanical heart valve and took warfarin, a blood thinner that prevents deadly clots but requires weekly monitoring through blood tests called International Normalized Ratio labs. Staff were supposed to draw the labs every Tuesday.
On October 22, 2024, they didn't.
Nobody told the medical provider about the missed test. Three days later, on October 25, the resident was rushed to the hospital with a stroke.
The patient arrived at the emergency room drowsy, with an acute stroke affecting the left middle cerebral artery, which supplies blood to a large portion of the brain. Doctors determined the resident was outside the window for clot-busting treatment and faced high hemorrhage risk. The stroke likely occurred because the resident's blood wasn't thin enough, inspectors concluded.
Assistant Director of Nursing #3 told inspectors that nursing staff filled out laboratory requests before the lab company arrived on Tuesdays and Thursdays. "If a resident's lab work was missed, they expected the medical provider to be notified immediately," the inspection report stated.
But that didn't happen.
The assistant director confirmed the resident's medical record showed orders for weekly blood tests. Labs were drawn on October 22, but didn't include the required International Normalized Ratio test. She couldn't explain why and acknowledged "the medical provider should have been notified on 10/22/2024 the lab was missed."
The breakdown extended beyond the missed test. Medical staff weren't even aware the resident had a mechanical heart valve, a critical diagnosis that requires more intensive blood monitoring than typical patients on warfarin.
Physician Assistant #4 told inspectors they learned about residents' conditions by reviewing hospital paperwork or diagnoses entered by admission nurses. For patients with both atrial fibrillation and mechanical heart valves, they expected blood levels maintained between 2.5 and 3.5 - higher than standard warfarin monitoring.
"They were not sure of the reason Resident #2's diagnosis of mechanical heart valve was not in their progress notes or in the resident record," inspectors wrote.
The physician assistant said if they had known about the mechanical valve, "they might have considered increasing the warfarin dose on 10/09/2024" when the resident's blood levels measured 1.9 - below the therapeutic range.
They never received notification about the missed October 22 lab work.
The Medical Director painted a picture of systemic communication failures during his September interview with inspectors. He said he learned about residents' diagnoses from nursing-entered diagnosis sheets and hospital records.
"If they did not document the resident had a mechanical heart valve in their 09/19/2024 History and Physical, they probably were not aware of the diagnosis, as it was their consistent practice to enter all diagnoses in which they were aware," the report stated.
The diagnosis should have appeared on the resident's care plan and diagnosis sheet. It didn't.
On October 9, when the resident's blood levels registered 1.9, the Medical Director said he "may have increased the resident's warfarin depending on previous trends." But without knowing about the mechanical valve, the urgency wasn't apparent.
When the missed lab work occurred on October 22, "they should have been notified in order to determine the next steps to be implemented."
The Medical Director's assessment was stark: "On 10/25/2024, when the resident was sent to the hospital, the lack of timely International Normalized Ratio monitoring and failure to maintain the resident's International Normalized Ratio in the recommended range for a mechanical heart valve could have contributed to the resident's stroke."
The inspection found actual harm to the resident, affecting few patients but representing a significant breakdown in medication monitoring protocols. Federal inspectors cited the facility for failing to ensure residents received proper treatment and services.
Crown Park is disputing the citation.
The resident's stroke left them with brain damage and drowsiness. They had been outside the window for thrombolytic therapy - the treatment that dissolves blood clots - by the time they reached the hospital. With a mechanical heart valve and acute stroke, doctors faced the dangerous balance of preventing more clots while avoiding hemorrhage.
The cascade of failures - missed lab work, lack of physician notification, incomplete diagnosis documentation, and subtherapeutic blood levels - converged on October 25 when the resident's blood wasn't thin enough to prevent the stroke that damaged their brain.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crown Park Rehabilitation and Nursing Center from 2025-09-04 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
CROWN PARK REHABILITATION AND NURSING CENTER in CORTLAND, NY was cited for violations during a health inspection on September 4, 2025.
Staff were supposed to draw the labs every Tuesday.
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.