Iowa ›Oskaloosa

Crystal Heights Care Center

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1514 High Avenue West, Oskaloosa, IA 52577 (opens Google Maps) · Mahaska County · (641) 673-7032· 72 certified beds · avg 67 residents/day · certified since Jun 1, 2006 · Medicare and Medicaid certified

Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →

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)

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

New to these records? How to read an inspection report →

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5 · how star ratings work →

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.

  1. 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

  2. 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

  3. 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.

DateSeverityWhat the facility was cited for
Dec 8, 2025D · Potential for more than minimal harm, isolatedThe 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, 2025E · Potential for more than minimal harm, patternThe 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, 2025E · Potential for more than minimal harm, patternThe 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, 2025D · Potential for more than minimal harm, isolatedThe 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, 2025D · Potential for more than minimal harm, isolatedThe facility did not honor residents' right to manage their own money and financial affairs. · F-0567
Jun 26, 2025D · Potential for more than minimal harm, isolatedThe 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, 2025D · Potential for more than minimal harm, isolatedThe 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, 2025D · Potential for more than minimal harm, isolatedThe 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, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide safe and appropriate pain management for a resident who needed it. · F-0697
Jun 26, 2025D · Potential for more than minimal harm, isolatedThe 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, 2025D · Potential for more than minimal harm, isolatedThe 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, 2025D · Potential for more than minimal harm, isolatedThe 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, 2023D · Potential for more than minimal harm, isolatedThe 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, 2023D · Potential for more than minimal harm, isolatedThe 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, 2023D · Potential for more than minimal harm, isolatedThe 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, 2023D · Potential for more than minimal harm, isolatedThe 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.

YearCitationsSerious (G–L)Worst severity that year
202340D
2025120E

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)

How to file a complaint about care →

1 fine totaling $10,489.

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.

DateTypeAmount / length
Dec 11, 2023Fine$10,489

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

What these staffing numbers mean →

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.

MeasureThis facilityIowa avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.664.373.95bottom 16% in Iowa; bottom 45% in the U.S.
Registered Nurse hours0.480.850.69bottom 11% in Iowa; bottom 35% in the U.S.
Weekend total nurse staffing3.083.863.50bottom 9% in Iowa; bottom 35% in the U.S.
Weekend RN hours (not acuity-adjusted)0.290.510.48bottom 13% in Iowa; bottom 30% in the U.S.
Total nursing staff turnover (%)63.544.045.8bottom 8% in Iowa; bottom 12% in the U.S.
RN turnover (%)—42.142.9—

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.

Quality measures rating: 2/5 · long-stay residents: 3/5 · short-stay residents: 2/5

Costs & payment

Price evidence · separate from quality

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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Understand who pays for care · How we handle price evidence · Report an incorrect price

Who owns this facility

How to read ownership records →

Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →

For profit - Corporation · changed ownership in the last 12 months

Owner / managerTypeRoleStakeSince
Gateway Healthcare LLCOrganizationDirect Ownership InterestNOT APPLICABLE05/21/2025
The Ensign Group INCOrganizationIndirect Ownership InterestNOT APPLICABLE05/21/2025
Burnam, SoonIndividualManaging Control - Governing BodyNOT APPLICABLE05/21/2025
Burnam, SoonIndividualOperational/Managerial ControlNOT APPLICABLE05/21/2025
Ensign Services INCOrganizationADP of the SNFNOT APPLICABLE05/21/2025
Jorgensen, DavidIndividualIndividual Is an Owner, Partner or Trustee of Any ADP of the SNFNOT APPLICABLE08/20/2025
Keetch, ChadIndividualIndividual Is an Owner, Partner or Trustee of Any ADP of the SNFNOT APPLICABLE08/20/2025
Koenig, DebraIndividualManaging Control - Governing BodyNOT APPLICABLE08/01/2025
Koenig, DebraIndividualOperational/Managerial ControlNOT APPLICABLE08/01/2025
Koenig, DebraIndividualADP of the SNFNOT APPLICABLE07/24/2025
Narrows Peak Health Holdings LLCOrganizationADP of the SNFNOT APPLICABLE08/01/2025
North, DavidIndividualManaging Control - Governing BodyNOT APPLICABLE08/01/2025
North, DavidIndividualOperational/Managerial ControlNOT APPLICABLE08/01/2025
North, DavidIndividualADP of the SNFNOT APPLICABLE07/24/2025
Port, BarryIndividualIndividual Is an Owner, Partner or Trustee of Any ADP of the SNFNOT APPLICABLE07/24/2025
Standard Bearer Healthcare Op, LPOrganizationADP of the SNFNOT APPLICABLE08/01/2025

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.

Listed by state, then facility name — not a ranking. Showing 8 of the 341 others, continuing from this facility's own place in that list.

Questions to ask on your visit

Full visit checklist →

Print visit checklist

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?"

Also worth asking anywhere

  • "Your weekend nurse staffing is reported below the Iowa midpoint — how does the weekend schedule differ from a weekday?"
  • "Can I see the plan of correction for the findings in your most recent state inspection?"
  • "CMS reports 64% total nursing staff turnover here — who on the care team has been with you longest?"
  • "CMS records an ownership change here in the last 12 months — what changed for residents and staff?"
  • "The ownership record on file lists 16 owning or managing parties — who makes the decisions about staffing levels?"
  • "Can I visit again unannounced, at a mealtime or on a weekend?"

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Oskaloosa Care Center0.4 miOskaloosa, IA★☆☆☆☆1/5
Northern Mahaska Specialty Care1.6 miOskaloosa, IA★★☆☆☆2/5
The Cottages15.9 miPella, IA★☆☆☆☆1/5

Compare this facility with the 3 closest →

All facilities in Oskaloosa →

Facility data as of CMS processing date 2026-08-01. CCN 165570.

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