Crystal Heights Care Center
1514 High Avenue West, Oskaloosa, IA 52577 · Mahaska County · 72 certified beds · avg 67 residents/day · certified since Jun 1, 2006
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 (16)
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 |
|---|---|---|
| Dec 8, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jun 26, 2025 | E · Potential for harm, repeated | 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. |
| Jun 26, 2025 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Jun 26, 2025 | 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. · from a complaint |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to manage their own money and financial affairs. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Jun 26, 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. · from a complaint |
| Dec 7, 2023 | 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. · from a complaint |
| Dec 7, 2023 | 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. |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Dec 7, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 4 | 0 | D |
| 2025 | 12 | 0 | E |
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)
1 fine totaling $10,489.
| Date | Type | Amount / length |
|---|---|---|
| Dec 11, 2023 | Fine | $10,489 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.66 | 4.37 | 3.95 | bottom 16% in Iowa; bottom 45% in the U.S. |
| Registered Nurse hours | 0.48 | 0.85 | 0.69 | bottom 11% in Iowa; bottom 35% in the U.S. |
| Weekend total nurse staffing | 3.08 | 3.86 | 3.50 | bottom 9% in Iowa; bottom 35% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.29 | 0.51 | 0.48 | bottom 13% in Iowa; bottom 30% in the U.S. |
| Total nursing staff turnover (%) | 63.5 | 44.0 | 45.8 | bottom 8% in Iowa; bottom 12% in the U.S. |
| RN turnover (%) | 0.0 | 42.1 | 42.9 | — |
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 3.07, RN 0.40, weekend 2.59. 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: 2/5 · long-stay residents: 3/5 · short-stay residents: 2/5
Who owns this facility
For profit - Corporation · changed ownership in the last 12 months
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Gateway Healthcare LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 05/21/2025 |
| The Ensign Group INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 05/21/2025 |
| Burnam, Soon | Individual | Managing Control - Governing Body | NOT APPLICABLE | 05/21/2025 |
| Burnam, Soon | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/21/2025 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/21/2025 |
| Jorgensen, David | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 08/20/2025 |
| Keetch, Chad | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 08/20/2025 |
| Koenig, Debra | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/01/2025 |
| Koenig, Debra | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2025 |
| Koenig, Debra | Individual | ADP of the SNF | NOT APPLICABLE | 07/24/2025 |
| Narrows Peak Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 08/01/2025 |
| North, David | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/01/2025 |
| North, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2025 |
| North, David | Individual | ADP of the SNF | NOT APPLICABLE | 07/24/2025 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 07/24/2025 |
| Standard Bearer Healthcare Op, LP | Organization | ADP of the SNF | NOT APPLICABLE | 08/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How are residents' personal funds handled here, and what records can families review?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "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 |
|---|---|---|---|---|---|
| Oskaloosa Care Center | 0.4 mi | Oskaloosa, IA | ★☆☆☆☆ | 1/5 | |
| Northern Mahaska Specialty Care | 1.6 mi | Oskaloosa, IA | ★★☆☆☆ | 2/5 | |
| The Cottages | 15.9 mi | Pella, IA | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165570.