Other·June 29, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey for the investigation of two complaints. Complaint numbers CA00580002 and CA00579963 Representing the California Department of Public Health: Surveyor Federal/State ID# 34435/2829, HFEN The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. A deficiency was issued for complaint numbers CA00580002 and CA00579963.

F757 SS=G Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 04/17/2018 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DPWB11 Facility ID: CA240000098 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056185 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure one (Resident A) in a sample of three residents in a universe of 71 residents, was free from unnecessary Coumadin (warfarin an anticoagulant or blood thinner) doses, when the ordered laboratory test for monitoring therapeutic range (PTProthrombin Time/INR-International Normalized Ratio) was not carried out. This failure resulted in excessive warfarin level, extensive bleeding, and hemorrhagic shock (severe fluid loss which makes it impossible for the heart to pump sufficient amount of blood into the body) for Resident A. Findings: On April 5, 2018, at 10 a.m., an unannounced complaint investigation was conducted at the facility. Resident A's record was reviewed. Resident A,who was 87 years old, was discharged from the acute hospital and arrived at the facility on March 17, 2018 with diagnoses that included congestive heart failure (CHF), atrial fibrillation (abnormal heart rhythm), and chronic ischemic heart disease (or CAD [coronary artery disease] - narrowed arteries causing less blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DPWB11 Facility ID: CA240000098 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056185 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and oxygen to the heart). Resident A's facility records included copies of records from the acute hospital which indicated: -Acute hospital history and physical, dated March 16, 2018, " ...87 year old female ...Coumadin (significant side effects include gastrointestinal bleeding and stroke resulting in serious injury or death) already with supratherapeutic (level greater than would be used for treatment) INR..." The document further indicated Resident A's INR on on March 15, 2018 was critical at 5.5 (normal range is between 0.9 and 1.1). -Acute hospital "SUMMARY OF CARE", which included discharge instructions to no longer take Coumadin 1 mg daily, "COAGULATION 3/17/2018 05:43:00 INR: 5.8 ...PT: 61.7-Normal range between 9.3 and 11.2 ..." Resident A's facility record further indicated: -Facility history and physical dated March 19, 2018 indicated, " ...Pt (patient) was placed on Keflex (antibiotic) for uti (urinary tract infection) and had her Coumadin (used to treat a blood clot in the lungs) held due to elevated INR ..." The document further indicated Resident A's current medication included Coumadin, " ...Take as directed by Anticoagulation clinic (sic) to thin blood ..." -Physician's order dated, March 19, 2018, "Hold Coumadin today, PT/INR (used to monitor how the blood thinning medication is working) 3/20/2018" -Physician's order dated, March 21, 2018, "Coumadin 2 mg (milligrams) po (by mouth) daily, next INR 3/23/18" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DPWB11 Facility ID: CA240000098 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056185 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE -Physician's order dated, March 23, 2018, "Cont. (continue) Coumadin 2 mg po daily, next INR 3/26/2018" -Physician's order dated, March 26, 2018, "Sent to (acute hospital) ER (emergency room) 911 ...vaginal bleeding" -The medication administration record indicated Resident A received Coumadin 2 mgs from March 22 through 25, 2018. On April 5, 2018, at 11:45 a.m., Resident A's record was reviewed with the Director of Nursing (DON). The DON stated Resident A was transferred to the acute hospital on March 26, 2018 because around 1:45 p.m., Resident A was noted to have copious amount of red blood from the vaginal area. The DON stated Resident A belonged to a specific managed care group who had their own anticoagulation clinic that managed all of the Coumadin dosing and monitoring for all residents that were under the managed care group. The DON stated the managed care anticoagulation clinic gave the order to start Resident A's Coumadin 2 mgs daily on March 20, 2018. The DON stated the physician's order dated March 21, 2018, "Coumadin 2 mg (milligrams) po (by mouth) daily, next INR 3/23/18" was based from the "(name of managed care group) Anticoagulation Service Supplemental Order" dated, March 20, 2018. The supplemental order indicated: Last INR Result: INR 2.4 3/20/2018, Warfarin Dosing Instructions: start 2mg daily, Next INR Date: Follow up date: 03/23/2018. The DON stated on March 23, 2018, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DPWB11 Facility ID: CA240000098 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056185 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE managed care anticoagulation clinic gave the order to continue Coumadin 2 mgs daily for Resident A. The "(name of managed care group) Anticoagulation Service Supplemental Order" dated, March 23, 2018, indicated: Last INR Result: INR 2.4 3/20/2018, Warfarin Dosing Instructions: continue 2mg daily, Next INR Date: Follow up date: 03/26/2018. The Coumadin dose was continued based on PT/INR result from March 20, 2018. Review of Resident A's printed laboratory results and the "LAB ORDER LOG FOR (name of managed care group) PATIENTS ONLY" with the DON indicated, the PT/INR ordered for Resident A to be drawn on March 23, 2018 was not carried out. The DON confirmed there was no documented evidence that the facility was aware and followed up on the missed PT/INR ordered for March 23, 2018. On April 5, 2018, at 1 p.m., the facility Case Manager (CM) was interviewed with the DON. The CM stated part of her responsibility was coordinating the care of residents that belonged to the managed care group. The CM stated she called the managed care anticoagulation clinic today. The CM stated she was told the PT/INR for Resident A was not carried out on March 23, 2018, because they (managed care group anticoagulation clinic laboratory) went to the wrong address for Resident A. Both the DON and the CM agreed the facility should have been monitoring Resident A's Coumadin dosing and PT/INR results. Resident A was subsequently admitted to the acute hospital on March 26, 2018. The acute FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DPWB11 Facility ID: CA240000098 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056185 (X3) DATE SURVEY COMPLETED 04/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MENIFEE LAKES POST ACUTE 27600 Encanto Dr Menifee, CA 92586 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hospital emergency department records indicated Resident A's INR was 8.2 on March 26, 2018. The acute hospital emergency department physician note, dated, March 26, 2018, 3:27 p.m, indicated, "...given the severity of bleeding 2 units of fresh frozen plasma (the liquid portion of human blood that has been frozen and preserved, used for blood transfusion) was ordered given her INR of over 8 in the context of heavy vaginal/GI (gastrointestinal) bleeding...Patient dropped her pressure (blood pressure) to become 80 over palp (palpation)...this time the patient remains hypotensive (low blood pressure)...Condition: Serious..." The acute hospital history and physical, dated March 26, 2018, indicated " ...Bleeding seemingly was so extensive that it was not possible to say if this was vaginal or rectal bleed ...Markedly increased INR (due to excessive warfarin) ...Hypotension, due to recurrent bleeding ..." The acute hospital physician progress note, dated March 27, 2018, 4:53 p.m., indicated "on Levophed (used to treat life-threatening low blood pressure)...received 3 units of blood and 4 units of fresh frozen plasma..." The acute hospital note dated, March 28, 2018, 3:23 p.m., indicated Resident A's "Admission Diagnosis(es): 1.) Extensive vaginal/rectal bleed, 2.) Excessive warfarin level... Primary Diagnosis: Hemorrhagic shock ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DPWB11 Facility ID: CA240000098 If continuation sheet 6 of 6