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Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
2/5
Health inspection rating (on-site)
inspected Jun 26, 2025
0
Serious findings on record
$10,489
Fines, last 3 years
3.66
Nurse hours/resident/day (adjusted)
Every record stays on this page.
What health inspectors found (on-site government inspections — the most independent evidence available)
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 quality measures from resident assessments and claims.
Inspection findings in the public record
Showing the latest 3 of 16 inspection findings. Open the full record below to read every finding.
D · Potential for more than minimal harm, isolated
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 complaintF-0760
E · Potential for more than minimal harm, pattern
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. F-0657
E · Potential for more than minimal harm, pattern
The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. F-0679
View all 16 inspection findingsShow only the latest 3 findings
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
Date
Severity
What the facility was cited for
Dec 8, 2025
D · Potential for more than minimal harm, isolated
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 · F-0760
Jun 26, 2025
E · Potential for more than minimal harm, pattern
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. · F-0657
Jun 26, 2025
E · Potential for more than minimal harm, pattern
The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. · F-0679
Jun 26, 2025
D · Potential for more than minimal harm, isolated
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 · F-0550
Jun 26, 2025
D · Potential for more than minimal harm, isolated
The facility did not honor residents' right to manage their own money and financial affairs. · F-0567
Jun 26, 2025
D · Potential for more than minimal harm, isolated
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. · F-0578
Jun 26, 2025
D · Potential for more than minimal harm, isolated
The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641
Jun 26, 2025
D · Potential for more than minimal harm, isolated
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. · F-0690
Jun 26, 2025
D · Potential for more than minimal harm, isolated
The facility did not provide safe and appropriate pain management for a resident who needed it. · F-0697
Jun 26, 2025
D · Potential for more than minimal harm, isolated
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. · F-0699
Jun 26, 2025
D · Potential for more than minimal harm, isolated
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 · F-0725
Jun 26, 2025
D · Potential for more than minimal harm, isolated
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 · F-0880
Dec 7, 2023
D · Potential for more than minimal harm, isolated
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 · F-0656
Dec 7, 2023
D · Potential for more than minimal harm, isolated
The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · F-0658
Dec 7, 2023
D · Potential for more than minimal harm, isolated
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. · F-0677
Dec 7, 2023
D · Potential for more than minimal harm, isolated
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. · F-0758
Inspection trend by year
Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations:
4
Serious citations (G–L):
0
2025
All citations:
12
Serious citations (G–L):
0
All bars start at zero. Exact values and supporting details remain below.
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.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
Date
Type
Amount / length
Dec 11, 2023
Fine
$10,489
Nurse staffing (from payroll records, adjusted for how much care residents need)
Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityIowa averageU.S. average
Total nurse staffing (hours per resident per day)
This facility:
3.66
Iowa average:
4.37
U.S. average:
3.95
Registered Nurse hours
This facility:
0.48
Iowa average:
0.85
U.S. average:
0.69
Weekend total nurse staffing
This facility:
3.08
Iowa average:
3.86
U.S. average:
3.50
All bars start at zero. Exact values and supporting details remain below.
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 (%)
—
42.1
42.9
—
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — 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.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.07 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 2/5.
Quality measures: assessments & claims
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
No verified facility-specific private-pay price is available in our data for Crystal Heights Care Center. CMS inspection and staffing records do not tell us what this home will charge you.
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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
All 16 owning or managing parties CMS has on file are shown — none excluded.
Other facilities in the same chain
CMS lists this facility under the chain The Ensign Group — 342 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.