Cottesmore of Life Care: Blood Thinner Failures - WA
Blood thinners are not a medication where missing doses is a minor inconvenience. Drugs like Warfarin and Rivaroxaban are prescribed to prevent blood clots, strokes, and pulmonary embolisms. Gaps in dosing can leave patients unprotected against exactly the events those medications are meant to stop.
Federal inspectors rated the violations as causing actual harm.
The problems surfaced on August 18, when inspectors questioned Staff C, a licensed practical nurse serving as Resident Care Manager, about why Resident 2 had not received Warfarin on August 7 and August 8. Staff C walked through the order history: Resident 2 had been prescribed Warfarin 5mg daily on most days of the week, with a separate Thursday dose of Warfarin 2.5mg set to begin August 7. Both orders were discontinued on August 7, the Thursday order at 11:39 in the morning, before the 5 p.m. administration time. Staff C said the resident should have received the Warfarin that day. The following day, August 8, it was held again.
Two doses gone.
Resident 3's situation was different but no less serious. The Director of Nursing Services, an RN identified in the report as Staff A, told inspectors that Resident 3 had an order for Rivaroxaban that was discontinued in error. The order should never have been stopped. Resident 3 should have kept receiving the medication daily. Staff A did not say how long the gap lasted before anyone noticed.
The case that triggered the audit was Resident 1. Staff B had flagged a discrepancy in that resident's Warfarin order and reported it to Staff A, who immediately ordered a review of all anticoagulant orders across the facility. What the audit found was that Resident 1's Warfarin order had been entered incorrectly into the electronic medication administration record. Because of that entry error, the resident went without Warfarin on August 13, 14, 15, 16, and 17.
Five consecutive days.
Staff A described the sequence to inspectors herself, including the part about the order being placed incorrectly into the system. She confirmed all three residents had been affected. She confirmed the doses were missed. And then she said something that stopped the inspection in its tracks: she was not aware of a policy for order reconciliation.
The Director of Nursing, responsible for overseeing medication management at the facility, did not know whether the facility had a process for verifying that medication orders are entered correctly and remain active when they should.
That absence, or that unawareness, is what connects all three cases. Resident 2's Warfarin was discontinued the same morning it was supposed to be given, and no one caught it before the dose was due. Resident 3's Rivaroxaban was discontinued entirely by mistake, and no one caught it until Staff B noticed something unrelated in Resident 1's record and Staff A ordered a sweep. Resident 1's order was entered wrong, and five days passed before anyone looked.
The inspection was conducted as a complaint investigation. The report does not say who filed the complaint or what specifically prompted it. It does not say whether any of the three residents suffered strokes, clots, or other consequences from the missed doses. What it says is that the harm was actual, not potential.
The facility is operated under the Life Care name in Gig Harbor, a small city on Puget Sound southwest of Tacoma. The inspection was completed August 18, 2025.
Three residents. At least eight missed doses of anticoagulants across a twelve-day window. And the person running nursing services at the facility could not say whether any formal process existed to make sure it didn't happen again.
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.
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 22, 2026 · Our methodology
COTTESMORE OF LIFE CARE in GIG HARBOR, WA was cited for violations during a health inspection on August 18, 2025.
Blood thinners are not a medication where missing doses is a minor inconvenience.
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.