Other·May 18, 2026

Regulatory Violations: California Code of Regulations, Title 22, Section § 72401 (a) (b) (d) (e) Optional Service Units -General. (a)“Optional service unit” means a functional unit of a skilled nursing facility which is organized, staffed and equipped to provide a specific type or types of patient care. A facility is not required to operate an optional service unit. (b)The following types of optional service units may be operated in a skilled nursing facility: physical therapy, occupational therapy, speech therapy, speech pathology, audiology, social work services, and special treatment program services. (d) Each optional service unit within the facility shall be approved by the Department. Any facility desiring approval for an optional service unit shall file an application on forms furnished by the Department. (e) The Department shall list on the facility license each optional service for which approval is granted. On 4/25/2026 at 8:30 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility during a Health Recertification Survey and a State complaint. During the survey, CDPH determined that the facility failed to obtain approval from the California Department of Public Health (CDPH) and contact the Department of Health Care Access and Information (HCAI, formally known as the Office of Statewide Health Planning and Development [OSHPD]) for certification of the building standards prior to the provision of home dialysis services that included Peritoneal Dialysis ([PD] a home-based treatment for kidney failure that uses a soft tube in the abdomen and special fluid to filter waste and extra water through the abdomen’s lining to drain the dirty fluid) Services for 11 residents (Residents 1, 2, 3, 4. 5, 6, 7, 8, 9, 10, and 11) from 5/23/2024 to 4/29/2026 (total of 23 months). During the investigation from 4/25/2026 through 4/29/2026, Resident 1 and Resident 2 were still residing at the facility and receiving PD treatments and services. As a result, State Agencies that included CDPH and HCAI were not able to conduct an onsite survey to ensure the provision of home dialysis treatments and care of residents requiring routine peritoneal dialysis treatments and services meets current standards of practice for the safe administration of the dialysis treatments. This deficient practice placed 11 residents at risk for serious complications due to the lack of State Agency oversight of the facility staff performing PD on residents. 1. A review of Resident 1's Admission Record (AR), the AR indicated the facility admitted Resident 1 on 2/8/2026 and readmitted on 4/16/2026 with diagnoses that included end stage renal disease (ESRD, failure of the filters waste, excess fluids, and toxins from the blood to create urine] no longer function well enough to meet a body's needs) and infection (the invasion and multiplication of microorganisms in body, causing tissue damage and disease) and inflammatory reaction (body’s defense mechanism against harmful stimuli) due to PD. A review of Resident 1’s Minimum Data Set (MDS, a resident assessment tool), dated 4/22/2026, the MDS indicated that Resident 1 received PD since admission. A review of Resident 1’s “Order Recap Report,” order date 2/21/2026, indicated Resident 1 received PD treatment by facility licensed staff from 2/21/2026 to 4/17/2026. A review of Resident 1’s Medication Administration Record (MAR) for April 2026 indicated that Resident 1 received PD treatment from facility licensed staff from 4/1/2026 to 4/4/2026 and 4/17/2026 to 4/26/2026. 2. A review of the Resident 2’s AR, the facility admitted Resident 2 on 2/24/2026 with diagnoses of ESRD and dependence on renal dialysis. A review of Resident 2’s MDS, dated 2/27/2026, the MDS indicated that Resident 2 received PD upon admission to the facility on 2/24/2026. A review of Resident 2’s “Order Recap Report,” dated 2/24/2026, indicated Resident 2 PD started on 2/25/2026 to 3/31/2026. A review of Resident 2’s “SNF - PD Patient Treatment Log,” the Log indicated Resident 1 received daily PD treatments provided by facility licensed staff from 3/4/2026 to 4/25/2026. 3. A review of Resident 3’s AR indicated the resident was admitted on 5/23/2024, with diagnoses that included ESRD, and dependence on renal dialysis. A review of Resident 3’s H&P, dated 5/24/2024, indicated that Resident 3 was admitted to the facility with ESRD and received PD treatment. A review of Resident 3’s “Order Recap Report,” order date 5/24/2024, indicated Resident 3 received PD by facility licensed staff from 5/26/2024 and ended 9/5/2024. A review of Resident 3’s MDS, dated 5/28/2024, indicated that Resident 3’s cognitive skills were intact, and Resident 3 received PD upon admission to the facility. 4. A review of Resident 4’s AR, the facility admitted Resident 4 on 10/30/2024 and readmitted her on 9/3/2025 with diagnoses that included ESRD, and dependence on renal dialysis. A review of Resident 4’s H&P, dated 9/4/2025, indicated that Resident 4 was admitted to the facility with ESRD and received PD treatments. A review of Resident 4’s “Order Recap Report,” order date 10/31/2024, indicated Resident 4 received PD treatment that was provided by facility licensed staff started on 10/31/2024 and ended 11/15/2024. A review of Resident 4’s “Order Recap Report,” order date 12/3/2024, indicated Resident 4 receive PD while residing at the facility on 12/3/2024 and ended 12/13/2024. A review of Resident 4’s “Order Recap Report,” order date 9/3/2025, indicated Resident 4 received PD from 9/3/2025 and ended 9/9/2025. A review of Resident 4’s “Order Recap Report,” order date 9/9/2025, indicated Resident 4 was to received PD treatment from 9/9/2025 and ended 9/20/2025. 5. A review of Resident 5’s AR, the facility admitted Resident 5 on 4/28/2025 with diagnoses that included ESRD and dependence of renal dialysis. A review of Resident 5’s “Order Recap Report,” order date 4/29/2025, indicated Resident 5 was to receive PD treatment while residing at the facility that started 4/30/2025 and ended 5/14/2025. A review of Resident 5’s MDS, dated 5/2/2025, the MDS indicated Resident 5 received PD treatments upon admission. 6. A review of Resident 6’s AR, the facility admitted Resident 6 with an initial admission date 6/24/2025 and then readmitted to the facility on 8/24/2025 with diagnoses that included DM, ESRD, and dependence on dialysis. A review of Resident 6’s H&P, signed and dated 6/26/2025, indicated that Resident 6 had the capacity to understand and make decisions, and Resident 6 was admitted to the facility with ESRD and received PD treatments. A review of Resident 6’s “Order Recap Report,” an order dated 6/24/2025, indicated Resident 6 received PD from 6/24/2025 and ended 8/19/2025. A review of Resident 6’s MDS, dated 6/27/2025, indicated Resident 6 received PD upon admission. 7. A review of Resident 7’s AR, the facility admitted Resident 7 on 7/7/2025 with diagnoses that included ESRD and renal dialysis. A review of Resident 7’s H&P, signed and dated 7/9/2025, the H&P indicated the resident does not have the capacity to understand or make decisions. A review of Resident 7’s MDS, dated 7/11/2025, indicated that Resident 7’s cognitive skills were intact, and Resident 7 received PD treatments upon admission. A review of Resident 7’s “Order Recap Report, order date 7/7/2025, indicated Resident 7 received PD while residing in the facility from 7/7/2025 and ended 8/4/2025. 8. A review of Resident 8’s AR, the AR indicated that the facility admitted Resident 8 with an initial admission date 8/18/2025 and then readmitted to the facility on 8/31/2025 with diagnoses that included ESRD, and dependence of renal dialysis. A review of Resident 8’s “Order Recap Report,” order date 8/19/2025, indicated Resident 8 received PD treatment for 9 hours starting at 8 PM. The order ended 8/27/2025. A review of Resident 8’s “Order Recap Report,” order date 8/20/2025, indicated Resident 8 received PD treatments from 8/20/2025 to 8/27/2025. A review of Resident 8’s H&P, signed and dated 8/21/2025, indicated that Resident 8 was admitted with ESRD on PD treatments. A review of Resident 8’s “Order Recap Report,” order date 8/31/2025, indicated Resident 8 received PD treatment for 9 hours starting at 8 PM. The order ended 9/4/2025. A review of Resident 8’s MDS, dated 9/5/2025, indicated that Resident 8 received PD treatment upon admission. 9. A review of Resident 9’s AR, the facility admitted Resident 9 on 10/28/2025 and readmitted Resident 9 on 12/22/2025 with diagnoses that included ESRD, dependence on dialysis, and infection and inflammatory reaction due to PD catheter. A review of Resident 9’s “Order Recap Report,” order date 10/29/2025, indicated Resident 9 received PD treatments at 8 PM each evening. The treatment started 10/29/2025 and ended 12/15/2025. A review of Resident 9’s updated “Order Recap Report,” order date 10/30/2025, indicated Resident 9 received PD treatment that started 10/30/2026 to 12/15/2025. A review of Resident 9’s MDS, dated 10/31/2025, indicated that Resident 9 received PD treatments upon admission. 10. A review of Resident 10’s AR, the facility admitted Resident 10 on 2/5/2026 and readmitted her on 4/16/2026 with diagnoses that included ESRD and dependence on dialysis. A review of Resident 10’s “Order Recap Report,” order date 2/6/2026, indicated Resident 10 received PD treatment at 8 PM every evening. The order ended 3/6/2026. A review of Resident 10’s MDS, dated 2/11/2026, indicated that Resident 10 received PD treatment upon admission. A review of Resident 10’s “Order Recap Report,” order date 3/9/2026, indicated Resident 10 received PD treatment that ended 3/12/2026. A review of Resident 10’s “Order Recap Report,” order date 3/12/2025, indicated Resident 10 received PD treatment 3/12/2025 to 3/19/2025. A review of Resident 10’s “Order Recap Report,” order date 3/22/2025, indicated Resident 10 received PD from 3/22/2026 to ended 4/1/2026. A review of Resident 10’s “Order Recap Report,” order dated 4/1/2025, indicated Resident 10 received PD treatment that started on 4/2/2026 and ended 4/10/2026. A review of Resident 10’s MDS, dated 4/7/2026, indicated that Resident 10 received PD treatments. A review of Resident 10’s “Order Recap Report,” order date 4/17/2026, indicated Resident 10 received PD treatment that started on 4/17/2026 and ended 4/22/2026. 11. A review of Resident 11’s AR, the facility admitted Resident 11 on 2/25/2026 with diagnoses that included DM, ESRD, and dependence on dialysis. A review of Resident 11’s MDS, dated 3/2/2026, the MDS indicated that Resident 11 received PD upon admission. A review of Resident 11’s “Order Summary Report,” dated 2/25/2026, indicated Resident 11 received PD treatment sat 8 PM each evening. The order ended 3/21/2026. A review of Resident 11’s “Order Summary Report,” an order dated 3/4/2026, indicated Resident 11 received PD treatment that started 3/4/2026 and ended 3/21/2026. A review of Resident 11’s MDS, dated 3/20/2026, indicated that Resident 11 was able to make independent and reasonable decisions for daily living, and Resident 11 received PD treatments upon admission. During the same concurrent observation and interview on 4/25/2026 at 11:22 AM in Resident 2’s room with Resident 2, Resident 2 stated he has been in the facility for almost three months and received home dialysis 7 days a week for 10 hours a day. Resident pointed to the white machine, and Resident 2 stated that was his PD machine. Resident 2 stated that the licensed nurses from the facility set up and connect his dialysis machine to his PD catheter around 6 PM or 7 PM before he goes to bed, and the nursing staff disconnects his PD catheter from the PD machine around 5 AM the next morning. During a concurrent observation and interview of another resident, Resident 1, on 4/25/2026 at 1:25 PM in Resident 1’s room, a PD machine was noted at bedside. Resident 1 stated that she has been in the facility for two months and the nurse from the facility performs the PD for her. During an observation on 4/25/2026 at 6:25 PM in Resident 1’s room, Licensed Vocational Nurse (LVN) 1 was observed preparing Resident 1’s PD machine for PD treatment. During an observation on 4/26/2026 at 6:24 AM with LVN 3 in Resident’s 1 room, Resident 1 was observed performing hand hygiene, disconnecting the PD tubing from her PD catheter, and wiped the PD catheter herself. LVN 3 was observed clamping the PD tubing and handing Resident 1 the sterile white cap to cover the PD catheter. During an observation and interview on 4/26/2026 at 11:30 AM in Resident 2’s room, Resident 2 was observed lying in bed and stated he had been receiving PD treatments at the facility. During a remote meeting conducted on 4/28/2026 at 11:30 AM with the facility Administrator (ADM), in the presence of the CDPH Program Managers (PMs) and Supervisors, the ADM stated that there were two residents currently residing at the facility who were receiving PD treatment and services. The ADM also stated that the facility’s nursing staff assisted these residents with initiating and disconnecting their PD treatments in the facility. During the same interview on 4/28/2026 at 11:35 AM with the ADM, CDPH PM, and Supervisors, the ADM stated that it “happened several years ago” when he “noticed” that residents discharged from the hospital had “PD or HD.” The ADM stated that he believed offering PD was a “nice service to offer to help the overall healthcare eco?care system.” The ADM also stated that he spoke with “[Clinic 1], his legal counsel, and his consultants” regarding offering PD in the facility. The ADM further stated that it was “his understanding that PD [did not] require the same level of requirements as HD.” During the same interview on 4/28/2026 at 11:40 AM with the ADM, CDPH PM, and Supervisors, the ADM stated that he “was aware of the All Facilities Letter (AFL, an official notice from CDPH sent to all healthcare facilities such as clinics, hospitals, and skilled nursing homes)” that indicated the facility needed to notify CDPH prior to the start of PD services in the facility. The ADM stated that, according to the regulatory reference “ESRD obligation and Title 22 (California Code of Regulations aimed at protecting the health, safety, and well?being of residents in licensed care facilities; regulations that act as the baseline licensing requirements for health facilities),” PD was not specifically identified under optional services. During the same interview on 4/28/2026 at 11:50 AM with the ADM, CDPH PM, and Supervisors, the ADM stated that the facility’s nursing staff received training from Clinic 1. The ADM also stated that “the facility has all the [dialysis] solutions and equipment to perform the procedure on hand.” During an interview on 5/1/2026 at 12:08 PM with the DON, the DON stated that she reviewed the resident’s medical records prior to accepting the resident into the facility and believed it was acceptable to admit residents receiving PD because the facility’s licensed nurses had been provided training by Clinic 1 and the facility had a written contract with Clinic 1. A review of the CDPH AFL titled “Updated Guidance for the Provision of Home Dialysis Services in a SNF,” revised on 3/8/2021, the AFL indicated that the “Centers of Medicare and Medicaid Services (CMS) requires the dialysis facility to notify CDPH of any arrangements” and “by submitting FORM CMS 3427 End Stage Renal Application and Survey and Certification (PDF) to CDPH.” A review of the same CDPH AFL titled “Updated Guidance for the Provision of Home Dialysis Services in a SNF,” revised on 3/8/2021, the AFL indicated that “SNFs seeking to provide peritoneal or hemodialysis services must apply for approval of the optional services.” The AFL indicated “any SNF seeking to initiate the provision of dialysis services in a SNF must submit a change of application to CDPH’s Centralized Application Branch (CAB) to request state approval to ad