Crystal Ridge Care Center

Name: Crystal Ridge Care Center
Address: 396 Dorsey Dr, Grass Valley, CA, 95945, US
Telephone: 5302722273

396 Dorsey Dr, Grass Valley, CA 95945 · Nevada County · 99 certified beds · avg 96 residents/day · certified since Sep 28, 1987

Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.86

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (45)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Apr 3, 2026	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint
Jan 15, 2026	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jul 24, 2025	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jun 26, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
May 23, 2025	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 23, 2025	D · Potential for harm, one-off	The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function.
May 23, 2025	D · Potential for harm, one-off	The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
May 23, 2025	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
May 23, 2025	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
May 23, 2025	D · Potential for harm, one-off	The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care.
May 23, 2025	D · Potential for harm, one-off	The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults.
May 23, 2025	D · Potential for harm, one-off	The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule.
May 23, 2025	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
May 23, 2025	D · Potential for harm, one-off	The facility did not provide routine dental care and 24-hour emergency dental care for residents.
May 23, 2025	D · Potential for harm, one-off	The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals.
May 23, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 23, 2025	D · Potential for harm, one-off	The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area.
May 23, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Dec 4, 2024	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Dec 4, 2024	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Dec 4, 2024	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Nov 26, 2024	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Nov 26, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint
Nov 26, 2024	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Nov 1, 2024	D · Potential for harm, one-off	The facility did not provide each resident with a nourishing, tasty, well-balanced diet that meets their daily nutritional and special dietary needs. · from a complaint
Dec 28, 2023	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Oct 7, 2022	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Oct 7, 2022	E · Potential for harm, repeated	The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Oct 7, 2022	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Oct 7, 2022	E · Potential for harm, repeated	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Oct 7, 2022	E · Potential for harm, repeated	The facility did not have enough support staff to safely and effectively run its food and nutrition service.
Oct 7, 2022	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Oct 7, 2022	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
Oct 7, 2022	D · Potential for harm, one-off	The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing.
Oct 7, 2022	D · Potential for harm, one-off	The facility did not dispose of garbage and refuse properly.
Mar 8, 2019	E · Potential for harm, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Mar 8, 2019	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 8, 2019	E · Potential for harm, repeated	The facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
Mar 8, 2019	E · Potential for harm, repeated	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Mar 8, 2019	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 8, 2019	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Mar 8, 2019	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Mar 8, 2019	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Mar 8, 2019	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Mar 8, 2019	D · Potential for harm, one-off	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (9 → 13).

Year	Citations	Worst severity that year
2019	10	E
2022	9	F
2023	1	D
2024	7	E
2025	16	E
2026	2	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.86	4.31	3.95	bottom 32% in California; top 45% in the U.S.
Registered Nurse hours	0.27	0.61	0.69	bottom 7% in California; bottom 7% in the U.S.
Weekend total nurse staffing	3.15	3.90	3.50	bottom 9% in California; bottom 39% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.14	0.51	0.48	bottom 2% in California; bottom 4% in the U.S.
Total nursing staff turnover (%)	46.5	36.7	45.8	bottom 21% in California; bottom 46% in the U.S.
RN turnover (%)	42.9	38.1	42.9	bottom 39% in California; bottom 49% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.70, RN 0.26, weekend 3.02. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Andrus, Roman	Individual	W-2 Managing Employee	NOT APPLICABLE	08/21/2023
Apt, Frederick	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Hancock, Mark	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Jergensen, Joshua	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Mitchell, John	Individual	Corporate Officer	NOT APPLICABLE	01/01/2024
Wolf, Salina	Individual	Contracted Managing Employee	NOT APPLICABLE	01/01/2024

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
"If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Golden Empire	0.6 mi	Grass Valley, CA	★★★★☆	3/5
Grass Valley Healthcare Center	0.6 mi	Grass Valley, CA	★★★☆☆	3/5
Wolf Creek Care Center	1.1 mi	Grass Valley, CA	★★★★☆	3/5
Westview Healthcare Center	19.3 mi	Auburn, CA	★★☆☆☆	1/5	abuse

Compare this facility with the 3 closest →

All facilities in Grass Valley →

Facility data as of CMS processing date 2026-08-01. CCN 555283.

The Care File

Visit checklist — Crystal Ridge Care Center

396 Dorsey Dr, Grass Valley, CA 95945 · 5302722273

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $0

Questions for the administrator:

☐ "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
☐ "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 555283 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)