Christ the King Manor: Warfarin Dosing Errors - PA
The errors involved warfarin, a medication that requires precise dosing. Too little, and blood clots can form on the artificial valve, traveling to the brain or lungs. Too much, and the risk of serious bleeding rises sharply. For a resident already living with a cerebral infarction, a loss of blood flow to the brain that had left him with physical deficits, the margin for error was narrow.
The resident, identified in the report only as Resident 93, had a physician's order dating to December 18, 2025, directing staff to give him 3.5 milligrams of warfarin every day. He did not receive a single dose from December 18 through December 21. His medication administration record confirmed the gap. Nobody gave him the medication. Nobody flagged it.
Five months later, in May 2026, the errors were different in form but no less serious in consequence.
A physician had written individualized daily orders for the resident: 4 milligrams on May 12, 3.5 milligrams on May 13, 4 milligrams on May 14, 3.5 milligrams on May 15. The alternating doses reflect the kind of careful titration warfarin patients often require, with a physician adjusting amounts to keep the blood's clotting time within a specific therapeutic range.
Staff gave him 7.5 milligrams on May 12. Nearly double the ordered dose. They gave him nothing on May 13. On May 14, they gave him 7.5 milligrams again. On May 15, nothing.
The medication administration record for May 2026 confirmed all of it.
The Director of Nursing, interviewed by inspectors on June 4, 2026, confirmed that a medication error had occurred in December and that the physician's warfarin orders had not been followed in May. The inspection report does not indicate that any explanation was offered for how either set of errors happened, or whether the resident suffered any documented harm as a result.
Resident 93 was cognitively intact, according to a quarterly assessment completed June 2, 2026. He understood what was happening around him. Whether he understood that his medication was being mismanaged, or had any way to know, the report does not say.
The inspection covered 35 residents. Warfarin errors were found for one.
Warfarin has been on the market since the 1950s and remains one of the most commonly prescribed anticoagulants in nursing homes. It is also one of the most frequently cited causes of preventable adverse drug events in older adults. Dosing errors, missed doses, and double doses each carry distinct risks, and the combination of both types of errors across two separate months at the same facility, for the same resident, is what inspectors documented here.
Christ the King Manor is located at 1100 West Long Avenue in DuBois. The inspection was completed June 4, 2026. The deficiency was cited under Pennsylvania nursing services regulations and rated as causing minimal harm or potential for actual harm.
The report does not say whether the resident's physician was notified of the December errors before May arrived. It does not say whether anyone reviewed the May administration record before inspectors did. It does not say what the resident's warfarin levels looked like during either period, or whether his blood was tested to check.
What the record shows is that a man with an artificial heart valve, a history of stroke, and a doctor's carefully written orders went without his blood thinner for days at a stretch, and received nearly twice the prescribed amount on two other days, across two separate months, at the same nursing home, before federal inspectors arrived and asked to see the paperwork.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Christ the King Manor from 2026-06-04 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
CHRIST THE KING MANOR in DUBOIS, PA was cited for violations during a health inspection on June 4, 2026.
The errors involved warfarin, a medication that requires precise dosing.
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.