Crystal Heights Care Center
1514 High Avenue West · Oskaloosa, IA · 52577 · 6416737032
72 certified beds For profit - Corporation Chain: The Ensign Group
Why this verdict
- Inspection results are getting worse cycle over cycle, not better.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Total nurse staffing below 3.0 hours per resident-day
2.94 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
64% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 2.94 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.34 | 0.55–0.75 |
| Weekend hours / resident-day | 2.51 | ≈ weekday level |
| Nursing turnover / year | 64% | median 45% |
| Fines (3-yr window) | 1 · $10,489 |
Inspection citations (16 in the current record)
-
Potential for harm · D December 8, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected December 15, 2025 · Pharmacy Service
-
Potential for harm · D June 26, 2025
Honor the resident's right to manage his or her financial affairs.
Corrected July 26, 2025 · Resident Rights
-
Potential for harm · D June 26, 2025
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.
Corrected July 26, 2025 · Resident Rights
-
Potential for harm · D June 26, 2025
Ensure each resident receives an accurate assessment.
Corrected July 26, 2025 · Resident Assessment and Care Planning
-
Potential for harm · E June 26, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected July 26, 2025 · Resident Assessment and Care Planning
-
Potential for harm · E June 26, 2025
Provide activities to meet all resident's needs.
Corrected July 26, 2025 · Quality of Life and Care
-
Potential for harm · D June 26, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected July 26, 2025 · Quality of Life and Care
-
Potential for harm · D June 26, 2025
Provide safe, appropriate pain management for a resident who requires such services.
Corrected July 26, 2025 · Quality of Life and Care
-
Potential for harm · D June 26, 2025
Provide care or services that was trauma informed and/or culturally competent.
Corrected July 26, 2025 · Quality of Life and Care
-
Potential for harm · D June 26, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 26, 2025 · Resident Rights
-
Potential for harm · D June 26, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected July 26, 2025 · Nursing and Physician Services
-
Potential for harm · D June 26, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected July 26, 2025 · Infection Control
-
Potential for harm · D December 7, 2023
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected January 7, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D December 7, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected January 7, 2024 · Quality of Life and Care
-
Potential for harm · D December 7, 2023
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.
Corrected January 7, 2024 · Pharmacy Service
-
Potential for harm · D December 7, 2023 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected January 7, 2024 · Resident Assessment and Care Planning
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| December 11, 2023 | Fine | $10,489 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 165570 · certified since June 1, 2006. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.