Inspection Reports for
Crystal Ridge Care Center
396 Dorsey Dr, Grass Valley, CA 95945, United States, CA, 95945
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
130% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 24, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where one resident allegedly struck another resident, raising concerns about resident-to-resident abuse.
Complaint Details
The complaint investigation substantiated that Resident 2 struck Resident 1 on the left side of the face, causing a small red mark and potential fear or distress. The incident occurred on 7/21/25 around 11 p.m. and was witnessed by Resident 3 and staff. Resident 2 admitted to pushing Resident 1 after being told to leave their room.
Findings
The facility failed to protect one resident from abuse when another resident hit them on the left side of the face, resulting in a small red mark and potential emotional distress. The incident was witnessed by a third resident and confirmed by staff and administration.
Deficiencies (1)
Failure to protect a resident from physical abuse by another resident, resulting in injury and potential emotional distress.
Report Facts
Residents involved: 3
Date of incident: Jul 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 1 | Conducted assessment of Resident 1 after the incident and reported observations. | |
| Administrator | Confirmed the incident and provided statements regarding the event and resident history. |
Inspection Report
Deficiencies: 1
Date: Jun 26, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with safety regulations related to preventing resident elopement and ensuring adequate supervision.
Findings
The facility failed to provide adequate supervision to prevent one resident with dementia from eloping outside the facility, resulting in the resident being missing for 45 minutes. The facility policy on wandering and elopements was reviewed, indicating efforts to identify at-risk residents and provide interventions.
Deficiencies (1)
Failed to provide adequate supervision to prevent one of three sampled residents from elopement outside the facility.
Report Facts
Wandering Risk Observation/Assessment score: 12
Brief Interview for Mental Status score: 0
Duration of elopement: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding Resident 1's elopement and supervision expectations |
| Licensed Nurse 1 | Licensed Nurse | Interviewed regarding Resident 1's exit-seeking behavior prior to elopement |
Inspection Report
Routine
Deficiencies: 4
Date: May 23, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in the nursing facility, focusing on medication administration, physician orders, resident safety, and adherence to care protocols.
Findings
The facility failed to ensure proper medication administration for Resident 50, including leaving medications at bedside; failed to follow physician's order for Resident 88 regarding the use of a neck brace; and did not follow the order to check placement of Resident 74's gastrostomy tube before medication administration. Additionally, Resident 82's wanderguard order was not followed, increasing elopement risk.
Deficiencies (4)
Resident 50's medications were left at bedside contrary to facility policy.
Resident 88 had no current physician's order for the use of neck brace despite wearing it.
Resident 74's order to check placement and flush gastrostomy tube before medication administration was not followed.
Resident 82's wanderguard was not worn as ordered, increasing risk of elopement.
Report Facts
Residents sampled: 26
Medications left at bedside: 7
Medication administration time: 6
Resident 50 BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse 4 (LN 4) | Gave Resident 50 medications and left pills at bedside | |
| Licensed Nurse 5 (LN 5) | Interviewed regarding medication policies and Resident 50's medication concerns | |
| Assistant Director of Nursing (ADON) | Provided information on self-administration policies and interdisciplinary care planning | |
| Director of Nursing (DON) | Stated expectations for medication administration and nurse adherence to physician orders | |
| Infection Preventionist (IP) | Described Resident 50's cognitive and behavioral status | |
| MDS Coordinator 1 and 2 | Confirmed Resident 82 was not wearing wanderguard bracelet | |
| Licensed Nurse 1 (LN 1) | Administered Resident 74's medications via gastrostomy tube without checking placement |
Inspection Report
Routine
Deficiencies: 11
Date: May 23, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication management, resident assessments, care planning, professional standards of care, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to identify irregularities in psychotropic medication orders, incomplete significant change assessments, inadequate care plan implementation, medication administration errors, failure to provide timely physician and dental visits, improper food storage, infection control lapses, and failure to provide adaptive eating equipment and accessible call lights.
Deficiencies (11)
Failure to identify irregularity in psychotropic medication order without a stop date for Resident 82.
Failure to initiate significant change in status assessment for Resident 294 after development of stage four pressure ulcer.
Failure to follow care plan to monitor newly identified behaviors for Resident 50.
Failure to provide care and services according to accepted professional standards for Residents 50, 88, and 74 including medication storage, use of neck brace, and gastrostomy tube care.
Failure to ensure timely physician visits every 30 days for Resident 14 during first 90 days of admission.
Medication administration errors including failure to count respirations before giving Dilaudid to Resident 32, failure to perform pre-flush of gastrostomy tube for Resident 74, and failure to wear gloves when handling hazardous medication for Resident 194.
Failure to provide timely dental treatment for Resident 14 despite prior recommendations.
Failure to provide adaptive eating equipment such as plate guard and two-handled cup with lid for Resident 10.
Failure to properly label and discard expired or undated food items in kitchen storage.
Infection control lapses including reconnecting contaminated gastrostomy tube port cap for Resident 74 and touching inside of resident's nosey cup with bare hands for Resident 40.
Failure to ensure call light was within reach of Resident 34 in bed.
Report Facts
Medication administrations of lorazepam: 31
Medication administrations of lorazepam: 38
Medication administrations of lorazepam: 27
Medication error rate: 12
Residents affected: 94
BIMS score: 11
BIMS score: 12
BIMS score: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 4 | Licensed Nurse | Named in medication administration and medication error findings related to Resident 50 |
| LN 5 | Licensed Nurse | Named in medication administration and medication error findings related to Resident 50 and Resident 194 |
| LN 1 | Licensed Nurse | Named in medication administration and infection control findings related to Resident 74 |
| DON | Director of Nursing | Interviewed regarding expectations for medication administration, infection control, and care planning |
| IP | Infection Preventionist | Interviewed regarding infection control practices and Resident 50 behavior |
| MDSC 1 | Minimum Data Set Coordinator | Interviewed regarding Resident 294 assessments |
| MDSC 2 | Minimum Data Set Coordinator | Interviewed regarding Resident 88 orders |
| Medical Records Director | Interviewed regarding monitoring and documentation of Resident 50 behaviors | |
| Medical Director | Interviewed regarding physician visits and staffing | |
| CNA 5 | Certified Nursing Assistant | Named in infection control finding related to touching inside of Resident 40's nosey cup |
| DS | Dietary Supervisor | Interviewed regarding food storage and labeling |
| RD | Registered Dietician | Interviewed regarding food storage and labeling |
Inspection Report
Routine
Deficiencies: 3
Date: Dec 4, 2024
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical services, medication storage, infection prevention and control, and overall facility regulatory requirements.
Findings
The facility failed to follow medication administration policies resulting in inaccurate documentation, failed to ensure medications were stored securely, and did not maintain a sanitary environment in a resident's room, with a sticky floor that posed an infection control risk. These deficiencies were found to have minimal harm or potential for actual harm affecting a few residents.
Deficiencies (3)
Failure to follow medication administration policy resulting in inaccurate documentation when a nurse signed for medication administration that was actually given by another nurse.
Medication stored in an unlocked drawer in a resident's bedside table, allowing potential unauthorized access.
Failure to maintain a sanitary environment as the floor in a resident's room was sticky despite daily mopping, posing a risk for infection spread.
Report Facts
Medication administration days signed by LN A: 8
Medication dose: 150
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN A | Licensed Nurse | Named in medication administration documentation deficiency. |
| LN B | Licensed Nurse | Observed and confirmed medication storage issues and medication identification. |
| DON | Director of Nursing | Confirmed medication administration and storage policies and reviewed related documentation. |
| HK | Housekeeper | Confirmed sticky floor condition and cleaning efforts. |
| HS | Housekeeping Supervisor | Confirmed sticky floor as infection control issue and lack of prior knowledge about urinal spills. |
| CNA C | Certified Nurse Assistant | Reported sticky floor condition despite daily mopping. |
| LN D | Licensed Nurse | Confirmed sticky floor condition and resident behavior contributing to it. |
| Infection Preventionist | Confirmed sticky floor as an infection control concern. |
Inspection Report
Routine
Deficiencies: 3
Date: Nov 26, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to respiratory care, medication administration, pharmaceutical services, and medication storage and labeling at Crystal Ridge Care Center.
Findings
The facility failed to provide an incentive spirometer to a resident as ordered, delayed administration of morning medications for three residents, and did not properly store and label medications, including keeping discontinued medications in active medication carts and mismatched physician and pharmacy instructions. These deficiencies posed potential risks for resident health and medication errors.
Deficiencies (3)
Failed to provide an incentive spirometer to Resident 2 as ordered, despite documentation indicating treatments were given.
Failed to administer morning medications in a timely manner to Residents 2, 3, and 4, resulting in delayed medication administration.
Failed to ensure medications were stored and labeled properly, including presence of discontinued medication in active medication cart, unlocked medication cart left unattended, and mismatched physician and pharmacy instructions for Pradaxa.
Report Facts
Residents sampled: 4
Residents affected: 1
Residents affected: 3
Medication doses not signed as given: 39
Medication doses not given on time: 39
Medication cart unlock incidents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse A | Licensed Vocational Nurse | Documented giving incentive spirometer treatment not actually given; had trouble logging into medication software; observed preparing medications including discontinued medication; observed leaving medication cart unlocked |
| Registered Nurse B | Registered Nurse | Reviewed physician orders and medication records; confirmed no incentive spirometer in resident's room; confirmed medication cart was unlocked and unsupervised |
| Director of Nursing | Director of Nursing | Reviewed medication administration records; confirmed medication delays and software login issues |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 1, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide a resident with a nourishing meal meeting his daily nutritional needs.
Complaint Details
Complaint investigation confirmed that Resident 1 did not receive the requested alternate meal on the night of 10/7/24 due to communication breakdown between CNA, dietary assistant, and kitchen staff. The complaint was substantiated by interviews and record review.
Findings
The facility failed to ensure that Resident 1 received an alternate meal as requested, resulting in the resident being hungry throughout the night. Interviews with the resident, CNA, and dietary staff confirmed communication failures between nursing and kitchen staff regarding meal substitutions.
Deficiencies (1)
Failure to provide Resident 1 with a nourishing meal meeting daily nutritional needs when the requested alternate meal was not delivered.
Report Facts
Residents affected: 2
BIMS score: 15
Date of Resident 1's Annual Minimum Data Set: Sep 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Interviewed regarding meal delivery and communication with kitchen staff | |
| Dietary Manager (DC) | Interviewed about the incident and communication failure regarding alternate meal |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 28, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to administer medication and perform blood sugar monitoring as ordered for Resident 1.
Complaint Details
The complaint involved failure to administer medication and blood sugar monitoring as ordered for Resident 1. The complaint was substantiated with findings of missed medication doses and incomplete blood sugar monitoring.
Findings
The facility failed to administer Famotidine medication at the correct times on six occasions and did not monitor Resident 1's blood sugar levels at the ordered frequency, missing bedtime checks. These failures caused discomfort to Resident 1 and posed potential risks for untreated blood sugar abnormalities.
Deficiencies (2)
Famotidine medication was not administered to Resident 1 at 6:00 am on 6 out of 15 days in December 2023 as ordered.
Blood sugar monitoring was ordered 4 times daily but was only performed 3 times daily, missing bedtime checks.
Report Facts
Missed medication doses: 6
Medication administration frequency: 2
Blood sugar monitoring frequency ordered: 4
Blood sugar monitoring frequency performed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LN 1 | Licensed Nurse | Confirmed missing documentation for medication administration and blood sugar monitoring errors |
| LN 2 | Licensed Nurse | Described medication administration documentation process and expectations |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 29, 2023
Visit Reason
The inspection was conducted following a complaint alleging physical abuse of one resident by another resident during a smoking break.
Complaint Details
The complaint investigation found substantiated physical abuse where Resident 2 kicked Resident 1's wheelchair causing pain and distress. Resident 1 was upset and sought retribution. The facility had policies to prevent abuse but failed in this instance.
Findings
The facility failed to protect Resident 1 from physical abuse when Resident 2 kicked the back of Resident 1's wheelchair, causing back pain and potential harm. Documentation and interviews confirmed the incident and subsequent resident distress.
Deficiencies (1)
Failure to protect Resident 1 from physical abuse by another resident, resulting in back pain and potential harm.
Report Facts
Date of abuse incident: Jan 18, 2023
Date of interviews: Feb 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| A | Licensed Nurse | Wrote Nurse's Note documenting Resident 1's complaint of back pain after incident |
| A | Social Services Assistant | Wrote Psychosocial Note following up with Resident 1 after the incident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 28, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged physical abuse of a resident by a Certified Nursing Assistant (CNA).
Complaint Details
The complaint was substantiated based on interviews and record reviews, including statements from the resident, a licensed nurse witness, and social services documentation describing the incident and resident's pain.
Findings
The facility failed to protect one resident from physical abuse when a CNA grabbed the resident's wrist roughly while providing care, potentially threatening the resident's health and well-being.
Deficiencies (1)
Failure to protect a resident from physical abuse by a CNA who grabbed the resident's wrist in a rough manner.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Named in physical abuse finding for grabbing Resident 3's wrist roughly. |
| LN C | Licensed Nurse | Witnessed the incident and provided statements regarding the abuse. |
Inspection Report
Routine
Deficiencies: 9
Date: Oct 7, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, grievance procedures, supervision, pain management, staff competencies, staffing levels, food and nutrition services, and sanitation practices.
Findings
The facility was found deficient in multiple areas including failure to protect residents' personal property, inadequate grievance communication, insufficient supervision of a wandering and aggressive resident, delayed pain management, lack of staff training on fire safety during smoking breaks, absence of a full-time registered nurse on duty, improper food sanitation and storage practices, and failure to properly secure garbage dumpster lids.
Deficiencies (9)
Failure to protect residents from loss of personal property due to unlabeled clothing items and unclear staff responsibilities.
Failure to make grievance filing procedures known to residents, limiting their ability to file written grievances.
Failure to provide adequate supervision for a resident with wandering and aggressive behaviors, resulting in unsafe conditions for other residents.
Failure to provide effective pain management for a resident due to staff not notifying the physician of consistent use of PRN pain medication.
Failure to ensure staff supervising resident smoking breaks were trained on fire safety equipment location and use.
Failure to provide a Registered Nurse on duty for eight consecutive hours daily, seven days a week.
Dietary staff failed to follow proper procedures for testing quaternary sanitizer concentration, risking foodborne illness.
Multiple unsafe and unsanitary food preparation and storage practices in the kitchen, including lack of air gap in prep sink, dirty ice machine, rusting shelves, chipped paint on refrigerator shelves, dirty ventilator fans, unclean microwaves and oven surfaces, dust and debris accumulation, cracked floors, expired food, and improperly stored ground beef.
Failure to ensure garbage dumpster lids were closed properly, risking pest attraction.
Report Facts
Resident PRN pain medication requests: 26
Unlabeled resident clothing items: 30
Residents affected by grievance issue: 5
Residents affected by supervision issue: 1
Residents affected by pain management issue: 1
Days without RN coverage: 4
Residents receiving food from kitchen: 83
Expired ice cream box: 1
Pieces of ground beef exposed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janitor (JAN) | Interviewed regarding responsibility for inventory and labeling of resident clothing. | |
| Housekeeping Manager (HM) | Interviewed regarding inventory and labeling of resident clothing. | |
| Social Services Assistant (SSA) | Interviewed regarding inventory of resident clothing and supervision of Resident 42. | |
| Receptionist (REC) A | Interviewed regarding inventory of resident clothing. | |
| Certified Nurse Assistant (CNA) A | Interviewed regarding inventory and labeling of resident clothing. | |
| Director of Staff Development (DSD) | Interviewed regarding staff training on inventory and labeling of resident clothing and fire safety training. | |
| Administrator (ADMIN) | Interviewed regarding grievance posting and staffing. | |
| Admissions Assistant (AA) A | Observed and interviewed regarding supervision of Resident 42. | |
| Treatment Nurse (TN) | Interviewed regarding Resident 42 and Resident 62 interactions. | |
| Licensed Nurse (LN) I | Documented aggressive behaviors of Resident 42. | |
| Licensed Nurse (LN) J | Documented aggressive behaviors of Resident 42. | |
| Licensed Nurse (LN) K | Documented aggressive behaviors of Resident 42. | |
| Social Services Assistant B | Documented Resident 42 pushing another resident. | |
| Licensed Nurse (LN) H | Documented increased aggressive behaviors of Resident 42. | |
| Licensed Nurse (LN) A | Interviewed regarding pain management procedures. | |
| Assistant Director of Nurses (ADON) | Interviewed regarding pain management and staffing. | |
| Certified Nurse Assistant (CNA) C | Observed and interviewed regarding fire safety knowledge during resident smoking breaks. | |
| Activity Assistant (AA) C | Interviewed regarding fire safety knowledge during resident smoking breaks. | |
| Human Resources (HR) | Provided employee record for CNA C. | |
| Administrator (ADMIN) | Interviewed regarding staffing and RN coverage. | |
| Staffing Coordinator | Confirmed days without RN coverage. | |
| RN Consultant | Interviewed regarding MDS policy. | |
| Dietary Aide A (DA A) | Observed testing quaternary sanitizer concentration. | |
| Dietary Aide B (DA B) | Observed testing quaternary sanitizer concentration. | |
| Food Services Efficiency Consultant (FSEC) | Observed and interviewed regarding kitchen sanitation issues. | |
| Certified Dietary Manager (CDM) | Interviewed and observed regarding kitchen sanitation and food safety. | |
| Maintenance Supervisor (MN) | Interviewed regarding ice machine cleaning. | |
| Activities Director (AD) | Interviewed regarding expired ice cream found in freezer. |
Inspection Report
Routine
Deficiencies: 9
Date: Mar 8, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, food safety, and care planning at Crystal Ridge Care Center.
Findings
The facility was found deficient in multiple areas including failure to promote dignified care during feeding, inaccurate resident assessments, delayed and incomplete care plans, inadequate activity programming, food safety violations, lack of policy for handling foods brought by visitors, incomplete medical records, and deficiencies in infection prevention and control practices.
Deficiencies (9)
Failure to promote a dignified dining experience when CNA wore gloves while feeding a resident.
Inaccurate completion of Minimum Data Set assessments for residents' hearing and urinary catheter use.
Failure to develop baseline care plans within 48 hours of admission for indwelling urinary catheter and fall risk.
Failure to develop and implement a person-centered activity care plan reflecting resident preferences.
Failure to develop comprehensive care plan within 7 days of assessment for indwelling urinary catheter.
Failure to maintain professional food service safety and sanitary conditions, including improper hand hygiene and food handling.
Lack of policy regarding use and storage of foods brought to residents by family and visitors.
Incomplete medical record: POLST form unsigned by physician.
Failure to maintain infection prevention and control program, including uncovered oxygen cannulas and improper glove use during resident care.
Report Facts
Residents sampled: 42
Residents sampled: 12
Residents sampled: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Named in dignity violation for wearing gloves while feeding Resident 67 |
| Director of Nursing | Director of Nursing | Interviewed regarding dignity policy and infection control |
| DSS | Assistant Director for Social Services | Interviewed regarding inaccurate MDS assessment for Resident 12 |
| MDS Coordinator 2 | MDS Coordinator | Interviewed regarding inaccurate MDS assessment and delayed care plans for Resident 41 |
| Activity Director | Activity Director | Interviewed regarding incomplete activity care plan for Resident 19 |
| RN 1 | Registered Nurse | Observed handling food trays without hand hygiene and touching hair |
| Food Nutrition Service Manager | Food Nutrition Service Manager | Interviewed regarding food handling and drying of brushes |
| CNA 9 | Certified Nursing Assistant | Interviewed regarding lack of policy for handling foods brought by visitors |
| Medical Records Director | Medical Records Director | Interviewed regarding unsigned POLST form |
| LVN 2 | Licensed Vocational Nurse | Interviewed regarding unsigned POLST form |
| CNA 1 | Certified Nursing Assistant | Observed and interviewed regarding improper glove use during resident care |
| LVN/Tx Nurse | Licensed Vocational/Treatment Nurse | Observed and interviewed regarding improper glove use during resident care |
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