Crystal Heights Care Center
1514 High Avenue West, Oskaloosa, IA 52577
Crystal Heights Care Center is a nursing home in Oskaloosa, Iowa. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating3 of 5
- Last standard health inspectionJuly 16, 2026 (3 months ago)
- Health citations since December 7, 202320 (Iowa average 21)
- Fines in the past three years1, $10,489 in total
- CMS flagsNone listed by CMS
Get an email when CMS publishes something new about this home
One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 4 of 5.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Changed ownership in the last 12 months
CMS no longer shows a change of ownership in the past 12 months.
Health inspection on August 20, 2026
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on September 1, 2026.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on September 1, 2026.
CMS has cited this home for F0690 2 times since 2025.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 2 of 5.
Changed ownership in the last 12 months
CMS records show a change of ownership in the past 12 months.
Health inspection on July 16, 2026
5 citationsCMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
58 of 387 Iowa homes (15%) got a citation at the actual harm level in 2026.
Show the 5 citations
Citation F0688. Severity G: actual harm, isolated.
The rule CMS cited:
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.
The home is disputing this citation through CMS's informal review.
CMS lists it as corrected on August 6, 2026.
Citation F0809. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on August 6, 2026.
Citation F0567. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to manage his or her financial affairs.
CMS lists it as corrected on August 6, 2026.
CMS has cited this home for F0567 2 times since 2025.
Citation F0679. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on August 6, 2026.
CMS has cited this home for F0679 2 times since 2025.
Citation F0865. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a plan that describes the process for conducting QAPI and QAA activities.
CMS lists it as corrected on August 6, 2026.
Fire safety inspection on July 16, 2026
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on July 29, 2026.
Citation K0324. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on July 17, 2026.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on July 28, 2026.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 27, 2026.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on July 21, 2026.
Citation K0923. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on July 17, 2026.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
Ownership
CMS lists this home under a new chain.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 3 of 5.
Name
CMS lists a new legal business name for this home.
Health inspection on December 8, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on December 15, 2025.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 5 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Name
CMS lists a new legal business name for this home.
CMS update of July 30, 2025
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on June 26, 2025
11 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 11 citations
Citation F0657. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 26, 2025.
Citation F0679. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide activities to meet all resident's needs.
CMS lists it as corrected on July 26, 2025.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on July 26, 2025.
Citation F0567. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to manage his or her financial affairs.
CMS lists it as corrected on July 26, 2025.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 26, 2025.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on July 26, 2025.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on July 26, 2025.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on July 26, 2025.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on July 26, 2025.
Citation F0725. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on July 26, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 26, 2025.
Fire safety inspection on June 26, 2025
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0161. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on July 22, 2025.
CMS has cited this home for K0161 2 times since 2024.
Citation K0271. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on July 22, 2025.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on July 22, 2025.
CMS has cited this home for K0353 2 times since 2024.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
CMS update of October 30, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5.
Fire safety inspection on August 8, 2024
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 15, 2024.
Citation K0161. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on August 21, 2024.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on August 22, 2024.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of April 25, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
December 11, 2023
FineCMS fine of $10,489 on December 11, 2023.
Health inspection on December 7, 2023
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on January 7, 2024.
CMS star ratings
- 3 of 5CMS overall star rating
- 3 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (641) 673-7032
- Last standard health inspection
- July 16, 2026 (3 months ago)
- Certified beds
- 72
- Residents per day, on average
- 66.9
- Ownership type
- For profit - Corporation
- Legal business name
- Canfield River Healthcare LLC
- Chain
- The Ensign Group
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Iowa average (20 vs 21).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- GATEWAY HEALTHCARE LLCDirect ownership interest · not applicable · since 05/21/2025
- THE ENSIGN GROUP INCIndirect ownership interest · not applicable · since 05/21/2025
- BURNAM, SOONOperational/managerial control · not applicable · since 05/21/2025
- KOENIG, DEBRAOperational/managerial control · not applicable · since 08/01/2025
- NORTH, DAVIDOperational/managerial control · not applicable · since 08/01/2025
Questions
When was Crystal Heights Care Center last inspected?
CMS lists July 16, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Crystal Heights Care Center have?
CMS lists 20 health citations since December 7, 2023. CMS also calls these deficiencies.
Has Crystal Heights Care Center been fined?
CMS lists 1 fine in the past three years, $10,489 in total.
What is the CMS star rating of Crystal Heights Care Center?
Its CMS overall star rating is 3 of 5.
Is Crystal Heights Care Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.