The patient at Bayview Rehabilitation and Healthcare Center had been admitted in November 2025 with deep vein thrombosis, a blood clot condition that can prove fatal if pieces break off and travel to the lungs. The resident was prescribed Warfarin, a powerful anticoagulant that prevents clots from forming or growing larger.
But the medication requires careful monitoring. Too little Warfarin leaves patients vulnerable to deadly clots. Too much causes dangerous bleeding.
On November 7, physicians ordered the resident to receive 3 milligrams of Warfarin every evening through November 13. A week later, doctors ordered a PT/INR blood test to measure how the medication was affecting the patient's blood clotting ability. The results would determine whether to continue the current dose, increase it, or decrease it.
The blood test was completed as ordered on November 14. The results came back the same day.
Nobody reviewed them.
Federal inspectors found no evidence that medical staff examined the PT/INR results on November 14. No evidence that anyone notified the attending physician. No evidence that anyone obtained new dosing orders for the resident's continued Warfarin therapy.
The resident received no Warfarin on November 14 or November 15.
Medication records show the patient had been receiving Warfarin daily since admission, except for those two critical days. The blood thinner resumed on November 16, but only after a three-day gap in monitoring and treatment.
On November 17, three days after the missed blood work review, facility staff finally transcribed a "Coumadin Alert" order. The alert required nursing staff to verify each evening shift that current Coumadin orders existed for the resident. Staff were instructed to document the patient's INR results and current dose with each shift change.
The alert system that could have prevented the medication gap wasn't implemented until after the violation occurred.
Registered Nurse Staff A told inspectors during a December 1 interview that she had been the resident's nurse during the day shift on November 14. She said the PT/INR results "may not have resulted before the end of her shift." But she couldn't provide evidence of any progress note addressing the blood test results. She also couldn't show that anyone had obtained Warfarin orders for November 14 or November 15.
The Director of Nursing acknowledged the system failure during her own interview with inspectors. She explained that Coumadin Alert orders "are usually transcribed to ensure staff administering medications are aware when a resident is on Coumadin therapy." She admitted the alert order wasn't put in place until November 17.
The nursing director also acknowledged that the resident missed Coumadin doses on both November 14 and November 15.
For patients with deep vein thrombosis, missing anticoagulant doses can have serious consequences. Blood clots can grow larger or new ones can form. Pieces of clots can break free and travel through the bloodstream to the lungs, causing pulmonary embolism, a potentially fatal condition.
The inspection found that Bayview failed to ensure residents remain free from significant medication errors. While inspectors classified the violation as causing "minimal harm or potential for actual harm," the two-day gap in blood thinner therapy for a patient with active blood clots represented a serious breakdown in medication management.
The facility's own alert system, implemented after the violation, demonstrates that staff understood the critical nature of Warfarin monitoring. The resident required daily verification of current orders, documentation of blood test results, and confirmation of proper dosing each shift.
The resident received that protection only after missing two doses of medication designed to prevent life-threatening complications from blood clots.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bayview Rehabilitation and Healthcare Center from 2025-12-01 including all violations, facility responses, and corrective action plans.