Crystal Heights Care Center
Oskaloosa, Mahaska County, Iowa · CCN 165570 · For-profit (Corporation) · part of The Ensign Group (342 facilities, chain average 3.2 stars)
CMS rates Crystal Heights Care Center 2 of 5 overall as of August 2026. 72 certified beds, 67 residents a day on average. 16 citations on record from the current inspection cycles; 1 fine totalling $10,489.
On record
- Changed ownership in the last twelve months.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★★☆☆☆ 2 of 5 |
| Staffing | ★★☆☆☆ 2 of 5 |
| Quality measures | ★★☆☆☆ 2 of 5 |
| Quality: long-stay / short-stay | 3 / 2 of 5 |
Staffing
| Total nurse staffing | 3.06797 hours per resident per day |
|---|---|
| Registered nurses | 0.40275 hours per resident per day |
| Weekend total | 2.58512 hours per resident per day |
| Nursing staff turnover | 63.5% |
| Administrators who left | 1 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2025-12-08 complaint survey |
Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-12-15 |
| 2025-06-26 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-07-26 |
| 2025-06-26 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-07-26 |
| 2025-06-26 complaint survey |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-26 |
| 2025-06-26 | Honor the resident's right to manage his or her financial affairs. Resident Rights Deficiencies · tag F0567 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-26 |
| 2025-06-26 | 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. Resident Rights Deficiencies · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-26 |
| 2025-06-26 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · tag F0641 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-26 |
| 2025-06-26 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-26 |
| 2025-06-26 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-26 |
| 2025-06-26 | Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · tag F0699 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-26 |
| 2025-06-26 complaint survey |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-26 |
| 2025-06-26 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-07-26 |
| 2023-12-07 complaint survey |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-07 |
| 2023-12-07 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-07 |
| 2023-12-07 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-07 |
| 2023-12-07 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-01-07 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2023-12-11 | Fine | $10,489 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Ensign Services Inc. Organization | adp of the snf | — | 2025-05-21 |
| Narrows Peak Health Holdings LLC Organization | adp of the snf | — | 2025-08-01 |
| Standard Bearer Healthcare Op, Lp Organization | adp of the snf | — | 2025-08-01 |
| Gateway Healthcare LLC Organization | direct ownership interest | — | 2025-05-21 |
| The Ensign Group Inc. Organization | indirect ownership interest | — | 2025-05-21 |
| Koenig, Debra Individual | adp of the snf | — | 2025-07-24 |
| North, David Individual | adp of the snf | — | 2025-07-24 |
| Jorgensen, David Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2025-08-20 |
| Keetch, Chad Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2025-08-20 |
| Port, Barry Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2025-07-24 |
| Burnam, Soon Individual | managing control - governing body | — | 2025-05-21 |
| Koenig, Debra Individual | managing control - governing body | — | 2025-08-01 |
| North, David Individual | managing control - governing body | — | 2025-08-01 |
| Burnam, Soon Individual | operational/managerial control | — | 2025-05-21 |
| Koenig, Debra Individual | operational/managerial control | — | 2025-08-01 |
| North, David Individual | operational/managerial control | — | 2025-08-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Crystal Heights Care Center.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Mahaska County.