Cottesmore Of Life Care
COTTESMORE OF LIFE CARE in GIG HARBOR, WA — inspection on August 18, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
2025 eMAR documented Resident 2 was ordered Warfarin.
The eMAR documented Resident 2 did not receive one dose of Warfarin on 08/07/2025.
The Warfarin flow sheet for Resident 2 documented an order was received on 08/04/2025 that read Warfarin Sodium Oral tablet give 2.5 MG every Thursday starting on 08/07/2025 with no stop date indicated.
This order was discontinued on 08/07/2025 (Thursday) at 11:59 AM prior to the dose to be administered at 5:00 PM.
The EHR for Resident 2 documented on 08/04/2025 provider ordered Warfarin Sodium Oral tablet give 2.5 MG by mouth every Thursday for atrial fibrillation to start on 08/07/2025 which the computer placed as the first dose to be given on the following Thursday. On 08/18/2025 at 3:40 PM, Staff C, RCM/LPN, was asked why Resident 2 did not receive their Warfarin on 08/07/2025 and 08/08/2025.
Staff C said, Resident 2 had orders for Warfarin 5mg one time a day on Monday, Tuesday, Wednesday, Friday, Saturday, and Sunday with a start date of 08/04/2025 which was discontinued on 08/07/2025 and an order dated 08/04/2025 to start on 08/07/2025 (Thursday) for Warfarin 2.5 MG one time a day every Thursday at 1700.
This order was discontinued on 08/07/2025 at 11:39 AM.
Staff C said, it looks like Warfarin was held on 08/08/2025.
Staff C said, Resident 2 should have received the Warfarin on 08/07/2025.On 08/18/2025 at 4:03 PM, Staff A, Director of Nursing Services (DNS)/RN said, Resident 3 had an order for Rivaroxaban that was discontinued in error.
Staff A said, the Rivaroxaban order should not have been discontinued, and Resident 3 should have continued to receive it daily.
Staff A said, Staff B had reported to Staff A the discrepancy in the Warfarin order for Resident 1 and immediately did an audit for all anticoagulants to ensure accuracy.
Staff A said, the Warfarin order for Resident 1 was placed incorrectly into the eMAR resulting in the resident missing five doses of Warfarin on the dates of 08/13/2025, 08/14/2025, 08/15/2025, 08/16/2025, and 08/17/2025.
Staff A said, the Warfarin order for Resident 2 was discontinued prior to the dose that was to be administered on 08/07/2025 preventing the resident from getting the dose for that day.
Staff A said she was not aware of a policy for order reconciliation.Reference: WAC 388-97-1060(3)(k)(iii).
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