Goldstar Rehabilitation and Nursing Center of Santa Monica
1340 15th Street, Santa Monica, CA 90404
Citation Number: 910007605
Citation Date: 01/10/2011
Violation Date: 4/16/2009
Class: AA
Penalty: $ 100000

On 4/16/09, a 60 year old resident who had multiple sclerosis was eating dinner at an activity-sponsored event at the facility, when he began to choke on meat that had been prepared by the activities director at her home, without adherence to the resident's prescribed diet. The resident lost consciousness for 10-15 minutes. Paramedics removed a 2-inch piece of meat and several smaller pieces from his throat and transferred him to the hospital, where he died 7 days later from brain damage caused by the lack of oxygen. The facility was cited because it failed to follow his doctor's order for a soft diet, which was needed because the resident had a chewing problem and was missing some of his teeth. Its failure led to the resident's death.