A Santa Monica nursing home has been fined $100,000 by the California Department of Public Health following an investigation into the death of a patient.

Dr. Mark Horton, director of the California Department of Public Health, announced that Goldstar Rehabilitation and Nursing Center, 1340 15th St. in Santa Monica, received an “AA citation” after an investigation found that alleged inadequate care led to the patient’s death. The fine issued to the facility is the highest amount and most severe penalty under state law.

The facility allegedly failed to ensure the health and safety of the patient when it did not follow its patient care policies and procedures, which resulted in the patient’s death, according to the department.

The case involved a 60-year-old man who died after choking during a meal he was served at an activity-sponsored event. The patient, who had a chewing problem and was on a mechanically altered, therapeutic diet, choked on meat that had been prepared without adherence to the patient’s prescribed diet, according to a Department of Public Health report.

The investigation found that the facility’s nursing staff allegedly failed to provide a prescribed “mechanically soft” diet, implement a plan of care, and ensure that the patient was served a diet as prescribed by the attending physician.

According to the department, all nursing facilities in California are required to be in compliance with applicable state and federal laws and regulations governing health care facilities. The facilities are required to comply with these standards to ensure quality of care.

By providing nursing facilities it licenses with penalties for various violations, the department “strives to protect the health and safety of vulnerable individuals,” Horton said.

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