Health inspection·November 1, 2024

F 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two residents (Resident 1) was provided with a nourishing meal to meet his daily nutritional need when Resident 1 did not receive a meal for. This deficient practice resulted in Resident 1 being hungry throughout the night. Findings: A review of the policy titled Food and Nutrition Services revised October 2017, indicated Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration and the preferences of each resident. A review of Resident 1 ' s admission Record (undated), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including epilepsy (seizure disorder), heart failure, depression, and bipolar disorder (personality disorder). A review of Resident 1 ' s Annual Minimum Data Set (a complete clinical assessment) dated 9/12/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, evaluates a person's cognition, [ability to think, learn, remember, use judgement, and make decisions] with scores from 00 to 15) with a score of 15 indicating his cognition was intact. A review of Resident 1 ' s Nutrition Care Plan revised 9/12/24, showed a documented intervention to Cater to food preferences; Res (Resident 1) continues to be quite particular about his food preferences and choice menu slips. CDM/FNS (Certified Dietary Manager) to continue to work with res in an attempt to meet his needs. During an interview on 10/7/24 at 2:40 pm, Resident 1 stated I ordered a change to the menu (for supper). I believe that day it (the dinner menu) was ravioli ' s and I changed it to a grilled cheese, a salad, and some chicken noodle soup. I had ordered it (the substitute meal) by 9:15 am and gave it (the slip) to a Certified Nursing Assistant (CNA). When dinner time came it (my dinner) was raviolis. Resident 1 indicated he sent the meal back to the kitchen and asked for the grilled cheese sandwich but never received it. Resident 1 stated They (the CNA) brought me a bunch of snacks. I did not want that. This goes on quite frequently. The kitchen says they did not get the new order. I was hungry that night. During an interview on 10/7/24 at 3:38 pm, CNA B indicated she remembered the night Resident 1 received raviolis for his meal. CNA B indicated Resident 1 did not want raviolis but asked for a grilled cheese sandwich, so she took the raviolis back to the kitchen and requested a grilled cheese (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555283 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crystal Ridge Care Center 396 Dorsey Drive Grass Valley, CA 95945 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)