Federal inspectors discovered the gap during a September complaint investigation at the 41-bed facility on East Main Street. Resident 24 had been prescribed warfarin sodium since January, seven months before admission, but staff never developed the required care plan for anticoagulation management.
The resident arrived June 24 with multiple serious conditions: end stage renal disease requiring dialysis, diabetes, heart failure, and intellectual disabilities. Physician orders from January showed prescriptions for warfarin in two strengths — 8 milligram and 1 milligram tablets — with instructions to give half a 1 mg tablet plus the 8 mg tablet daily, totaling 8.5 mg to treat and prevent blood clots.
Warfarin requires careful monitoring because the medication can cause dangerous bleeding if levels become too high, or fail to prevent clots if doses are insufficient. Patients typically need regular blood tests and dietary counseling, since foods high in vitamin K can interfere with the drug's effectiveness.
The facility's care plan dated July 20 contained no mention of anticoagulant therapy.
When inspectors interviewed the Director of Nursing on September 24 at 2:34 p.m., she confirmed that Resident 24 had no plan of care for anticoagulant medication use. Federal regulations require nursing homes to develop comprehensive care plans addressing all resident needs, with measurable actions and timetables.
The missing care plan represented what inspectors called an "incidental finding" discovered while investigating an unrelated complaint. The violation affected one of three residents whose care plans inspectors reviewed during the September 25 inspection.
Care plans serve as roadmaps for daily treatment, outlining how staff should monitor residents, what symptoms to watch for, and when to contact physicians. For anticoagulation therapy, plans typically specify monitoring schedules, dietary restrictions, and protocols for managing bleeding risks.
The inspection report classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. However, anticoagulation errors rank among the most common medication-related injuries in healthcare settings.
Resident 24's complex medical conditions made proper anticoagulation planning particularly crucial. End stage renal disease can affect how the body processes warfarin, while intellectual disabilities might complicate the resident's ability to report symptoms of bleeding or clotting problems.
The facility had nearly four months to develop the missing care plan after the resident's admission. Staff would have reviewed physician orders showing the warfarin prescription and should have incorporated anticoagulation management into the comprehensive treatment approach.
Federal inspectors noted the deficiency under regulation F656, which requires facilities to "develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured." The regulation aims to ensure residents receive individualized care addressing their specific medical conditions and risks.
The violation occurred at a facility already operating under complaint investigation when inspectors arrived September 25. The report does not specify what prompted the original complaint that led to the inspection.
Cridersville Nursing and Rehab must submit a plan of correction detailing how it will address the care planning deficiency and prevent similar oversights. The facility has not yet filed its response with state survey agencies.
The resident continued receiving the prescribed warfarin throughout the period without a care plan, according to the inspection narrative. However, the absence of formal protocols meant staff lacked specific guidance for monitoring the resident's response to therapy or managing potential complications.
For a resident with multiple chronic conditions requiring dialysis three times weekly, the missing anticoagulation care plan represented a significant gap in treatment coordination. Dialysis patients face particular bleeding risks, and warfarin therapy requires careful balance between preventing clots and avoiding hemorrhage.
The Director of Nursing's confirmation that no anticoagulation care plan existed suggests the oversight was not a documentation error but an actual failure to develop required treatment protocols. Federal surveyors expect nursing homes to maintain current, comprehensive care plans reflecting all aspects of resident care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cridersville Nursing and Rehab from 2025-09-25 including all violations, facility responses, and corrective action plans.
Additional Resources
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