Nursing homes › Iowa › Crystal Heights Care Center
1514 High Avenue West, Oskaloosa, IA 52577 · 6416737032 · 72 certified beds
Per CMS filings, this facility is affiliated with The Ensign Group, a group operating 346 facilities in 17 states. Group record: average rating 3.2/5, 33 abuse citation icons, 9 facilities on the Special Focus list, $7,179,329 in federal fines. This facility rates below its group average (3.2/5).
Total nurse staffing: 3.07 (Iowa median: 3.69). RN hours: 0.40. Weekend total: 2.59. Nursing staff turnover: 64%.
All-time on record: 16 deficiency citations. Below: citations from 2023 onward (severity letters explained in methodology).
| Survey date | Deficiency | Sev. | Type | Status |
|---|---|---|---|---|
| 2025-12-08 | Ensure that residents are free from significant medication errors. | D | complaint | corrected 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. | E | Health | corrected 2025-07-26 |
| 2025-06-26 | Provide activities to meet all resident's needs. | E | Health | corrected 2025-07-26 |
| 2025-06-26 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | complaint | corrected 2025-07-26 |
| 2025-06-26 | Honor the resident's right to manage his or her financial affairs. | D | Health | corrected 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. | D | Health | corrected 2025-07-26 |
| 2025-06-26 | Ensure each resident receives an accurate assessment. | D | Health | corrected 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. | D | Health | corrected 2025-07-26 |
| 2025-06-26 | Provide safe, appropriate pain management for a resident who requires such services. | D | Health | corrected 2025-07-26 |
| 2025-06-26 | Provide care or services that was trauma informed and/or culturally competent. | D | Health | corrected 2025-07-26 |
| 2025-06-26 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | D | complaint | corrected 2025-07-26 |
| 2025-06-26 | Provide and implement an infection prevention and control program. | D | complaint | corrected 2025-07-26 |
| 2023-12-07 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | complaint | corrected 2024-01-07 |
| 2023-12-07 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Health | corrected 2024-01-07 |
| 2023-12-07 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | Health | corrected 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. | D | Health | corrected 2024-01-07 |
| Date | Type | Amount |
|---|---|---|
| 2023-12-11 | Fine | $10,489 |
| Name | Role | Type | % | Since |
|---|---|---|---|---|
| GATEWAY HEALTHCARE LLC | Direct Ownership Interest | Organization | NOT APPLICABLE | since 05/21/2025 |
| THE ENSIGN GROUP INC | Indirect Ownership Interest | Organization | NOT APPLICABLE | since 05/21/2025 |
| BURNAM, SOON | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 05/21/2025 |
| KOENIG, DEBRA | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 08/01/2025 |
| NORTH, DAVID | Managing Control - Governing Body | Individual | NOT APPLICABLE | since 08/01/2025 |
| BURNAM, SOON | Operational/Managerial Control | Individual | NOT APPLICABLE | since 05/21/2025 |
| KOENIG, DEBRA | Operational/Managerial Control | Individual | NOT APPLICABLE | since 08/01/2025 |
| NORTH, DAVID | Operational/Managerial Control | Individual | NOT APPLICABLE | since 08/01/2025 |
Source: CMS Provider Data Catalog (July 2026 release) — provider file, deficiency file, ownership file, penalty file. CCN 165570. Corrections: data@carerecords.org.