Crystal Ridge Care Center
396 Dorsey Drive, Grass Valley, CA 95945
Citation Number: 230008564
Citation Date: 09/21/2011
Violation Date: 2/8/2011
During a bath on 2/8/11, a male resident fell from a mechanical lift and landed in an empty tub, causing a broken neck and head lacerations. The resident was paralyzed, suffered respiratory failure, and passed away four days later. The facility's mechanical lift policy required two staff members perform transfers but only one CNA was operating the lift when the resident fell. The CNA was a hospice aide who had little experience or training in operating mechanical lifts. The facility was cited for failing to provide supervision and assistance to residents to prevent accidents.