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F0725
E

Insufficient Staffing Limits Dining Room Access for Meals

Santa Monica, California Survey Completed on 06-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to ensure the dining room was open and available to residents for all meals, as required. Observations and interviews revealed that residents were only able to eat in the dining room for lunch, while breakfast and dinner were typically served in residents' rooms. The activity director confirmed that since their employment, the dining room had only been used for lunch, and was unaware of the reason for this practice. The restorative nursing assistant also stated that the dining room opened at 9:00 a.m. and closed at 4:00 p.m., with breakfast being served in residents' rooms and uncertainty about dinner service due to their shift ending before dinner time. Staffing records and interviews indicated significant staffing challenges, including multiple certified nursing assistants calling off and being replaced by registry staff or other personnel. The director of nursing initially stated that residents could eat in the dining room for any meal, but later acknowledged, after speaking with the activity director, that the dining room was not always open for dinner due to insufficient staff to monitor residents during meals. This lack of staffing directly impacted residents' ability to exercise their right to dine in the dining room at all mealtimes. A resident with a history of hemiplegia, hemiparesis, stroke, and other medical conditions reported that he normally ate dinner in his room because there was not enough staff to facilitate dinner in the dining room. This issue had been previously discussed with the former administrator but remained unresolved. The facility's own policy stated that staffing levels should be based on resident needs and care plans, and that support services should be adequately staffed to meet those needs, which was not met in this instance.

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