Federal inspection record · CMS data as of October 1, 2026
Crystal Heights Care Center
1514 High Avenue West, Oskaloosa, IA · (641) 673-7032
- Certified beds
- 72
- Residents per day
- 67
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- June 1, 2006
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Iowa.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Iowa homes
Crystal Heights Care Center carries 38 inspection points. That is fewer than 45% of Iowa's 385 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Iowa: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–7 pts
- 4★ 7–21 pts
- 3★ 21–41 pts
- 2★ 41–86.5 pts
- 1★ over 86.5 pts
Bars show every rated home in Iowa by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
20 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (1)
-
G
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Everything else, by area of care
Quality of Life and Care6E
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide activities to meet all resident's needs.
- E
Provide activities to meet all resident's needs.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide safe, appropriate pain management for a resident who requires such services.
- D
Provide care or services that was trauma informed and/or culturally competent.
Resident Assessment and Care Planning4E
- D
Ensure services provided by the nursing facility meet professional standards of quality.
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Rights4D
- D
Honor the resident's right to manage his or her financial affairs.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- D
Honor the resident's right to manage his or her financial affairs.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Nutrition and Dietary1E
- E
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Administration1D
- D
Have a plan that describes the process for conducting QAPI and QAA activities.
Pharmacy Service1D
- D
Ensure that residents are free from significant medication errors.
Nursing and Physician Services1D
- D
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Infection Control1D
- D
Provide and implement an infection prevention and control program.
Inspection history
2026-07-16
8 health deficiencies · 6 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2025-06-26
11 health deficiencies · 3 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2024-08-08
1 health deficiencies · 3 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
4
Nursing time per resident, per day
Each resident here gets about 3 h 4 min of nursing staff time a day, 25 min of it from a registered nurse.
This home
3 h 4 min
Iowa average
3 h 52 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 57% of nursing staff and 0% of registered nurses left in the past year, along with 1 administrator.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$10,489 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2023-12-11 | Fine | $10,489 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.5 pts better | 0.9 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.6 pts better | 1.3 | 1.9 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine6.2 pts worse | 88.0% | 94.2% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine2.1 pts worse | 93.7% | 95.8% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.1 pts worse | 4.0% | 3.9% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms1 pts better | 3.2% | 4.2% | 13.5% |
| Percentage of long-stay residents who lose too much weight3.6 pts worse | 8.0% | 4.4% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.4 pts worse | 21.4% | 21.0% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication15 pts worse | 34.8% | 19.8% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.2 pts better | 0.0% | 0.2% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened5.3 pts better | 9.9% | 15.2% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased3.4 pts worse | 20.0% | 16.6% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.2 pts better | 1.2% | 1.4% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection2.8 pts worse | 5.2% | 2.4% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence0.9 pts better | 24.1% | 25.0% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.8 pts better | 2.3% | 4.1% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine36.7 pts worse | 47.3% | 84.0% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit9 pts better | 4.0% | 13.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication5.4 pts worse | 7.5% | 2.1% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine61.1 pts worse | 13.3% | 74.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission8.2 pts better | 12.5% | 20.7% | 23.4% |
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Who owns and runs it
16 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Burnam, Soon | Managing Control - Governing Body · Individual | 0% | 353 facilities |
| Burnam, Soon | Operational/Managerial Control · Individual | 0% | 353 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Gateway Healthcare LLC | Direct Ownership Interest · Organization | 0% | 14 facilities |
| Jorgensen, David | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 56 facilities |
| Keetch, Chad | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 301 facilities |
| Koenig, Debra | Managing Control - Governing Body · Individual | 0% | 7 facilities |
| Koenig, Debra | Operational/Managerial Control · Individual | 0% | 7 facilities |
| Koenig, Debra | Adp Of The SNF · Individual | 0% | 7 facilities |
| Narrows Peak Health Holdings LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| North, David | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| North, David | Operational/Managerial Control · Individual | 0% | 2 facilities |
| North, David | Adp Of The SNF · Individual | 0% | 2 facilities |
| Port, Barry | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 203 facilities |
| Standard Bearer Healthcare Op, LP | Adp Of The SNF · Organization | 0% | 78 facilities |
| The Ensign Group Inc | Indirect Ownership Interest · Organization | 0% | 135 facilities |
·
Fire safety
12 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke4F
- F
Provide properly protected cooking facilities.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Inspect, test, and maintain automatic sprinkler systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
Egress2E
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- D
Have exits that are accessible at all times.
Construction2F
- F
Use approved construction type or materials.
- E
Use approved construction type or materials.
Emergency Preparedness1F
- F
Conduct testing and exercise requirements.
Miscellaneous1F
- F
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems1E
- E
Have proper medical gas storage and administration areas.
Services1E
- E
Have properly installed electrical wiring and gas equipment.
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Other homes nearby
-
Oskaloosa Care Center
Oskaloosa, IA
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 33 min
- Fines
- $45,354
-
Northern Mahaska Specialty Care
Oskaloosa, IA · Care Initiatives
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 28 min
- Fines
- $39,033
-
The Cottages
Pella, IA · Wesleylife
★★★★★- Worst citation, 3 yrs
- K
- Nursing / resident / day
- 4 h 13 min
- Fines
- $52,060