See every facility — official ratings, family reviews, no referral fees.
Nursing HomeMedicaid Investigative

Crystal Heights Care Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1514 High Avenue West, Oskaloosa, IA 5257772 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.4/5

based on 40 Google reviews

5
4
3
2
1
Crystal Heights Care Center Nursing Home in Oskaloosa, IA — Street View
Street View

Watch Crystal Heights Care Center

Get an email when new inspections, ratings, or penalties are published for this facility.

We’ll only email you about this — no spam, unsubscribe anytime.

5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (12 vs median 5)
  • High staff turnover (60%)

Below average in IA · Critically understaffed (RN) · Significantly below average staffing · $10,489 in fines

Source: Medicare data

What this means for your family

Crystal Heights is highly regarded for its rehabilitation therapy and compassionate daily care, making it a strong candidate for recovery needs. However, because recent families have reported difficulty reaching the facility for admissions, we recommend visiting in person to verify their current communication standards and staffing availability.

Google Reviews

Google Reviews

40 reviews on Google
Crystal Heights Care Center receives high praise for its rehabilitation services and compassionate, long-term care staff, with many families noting that their loved ones feel treated like family. However, the facility has faced serious, albeit older, allegations regarding neglect and communication failures, as well as recent reports of difficulty reaching staff for admissions inquiries. Families should weigh the strong clinical and therapy outcomes against the inconsistent administrative responsiveness.

Quality Themes

Tap a score for details
Food8.0Staff8.0Clean3.0Activities7.0MedsN/AMemory9.0Comms4.0ValueN/A

Strengths

  • Effective physical and occupational therapy
  • Compassionate and attentive nursing staff
  • Strong, family-oriented care culture
  • Professional and knowledgeable clinical team

Concerns

  • Poor communication and lack of responsiveness to inquiries (mentioned by 2 reviewers)
  • Allegations of neglect or lack of supervision leading to falls (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

234'14(1)'16(3)'19(1)'24(1)'26(16)

Distribution · 43 analyzed

5
36
4
1
3
0
2
0
1
6
12 reviews posted between Jan 20, 2026Jan 21, 2026 · 12 were 5-star

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Given the recent focus on enhancing our internal processes, what specific steps is the facility taking to improve communication and responsiveness for families?
  • 2I noticed the facility has a strong reputation for physical and occupational therapy; how do you integrate those services into a resident's daily routine to ensure they stay active?
  • 3With the recent attention to resident safety and fall prevention, what specific protocols or supervision measures are in place to ensure my loved one remains safe during their daily activities?
  • 4How does the team balance the clinical care requirements with the goal of maintaining the family-oriented culture that many residents appreciate here?
  • 5We understand that maintaining a clean environment is a priority; could you walk us through your current housekeeping schedule and how you ensure high standards of cleanliness throughout the facility?
  • 6In the event of a medical concern or an emergency, what is the exact process for notifying family members so we stay fully informed?

Personalized based on this facility's data


Key Review Excerpts

The therapy he received (physical, occupational, and speech) was very helpful and made a huge difference in his recovery.

Memory care family member · 2025★★★★★

They know how to gently divert him when he's grumpy/angry. They work with him on how to use his walker more safely (because he won't listen to us!).

Long-term resident's family · 2025★★★★★

The staff were very professional and took great care of my grandparents as they got back on their feet.

Long-term resident's family · 2026★★★★★
Source: 40 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.34hrs
46%
Registered nurses for medical care
Total Nursing
2.94hrs
72%
All nurses + aides combined
Staff Turnover
64%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 16 measures

Medicare Rating
4/ 5
Better Than Avg

8

measures

Worse Than Avg

6

measures

Mixed Results

2

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility36.3%
Worse than Avg
Here
36.3%
US
15.5%
IA
19.4%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility14.5%
Better than Avg
Here
14.5%
US
19.4%
IA
25.9%
🦠

Residents who got a urinary tract infection

↓ Lower is better
This Facility9.8%
Worse than Avg
Here
9.8%
US
1.6%
IA
2.5%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility20.2%
Worse than Avg
Here
20.2%
US
14.4%
IA
17.6%
😔

Residents with depression symptoms

↓ Lower is better
This Facility6.7%
Mixed vs Avgs
Here
6.7%
US
12.1%
IA
4.1%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility12.1%
Better than Avg
Here
12.1%
US
15.3%
IA
17.5%
Short-Stay Residents (Rehab / Post-Acute)
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
IA
2.0%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility83.1%
Mixed vs Avgs
Here
83.1%
US
81.8%
IA
84.1%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

12deficiencies
1penalties
Well above state avg (6.2)
5 complaint-triggered
$10,489 in fines

Crystal Heights Care Center shows recurring problems across multiple surveys, with families filing five complaint reports in recent years. The facility has persistent issues with medication management, care planning, and building safety that repeat across surveys, particularly with sprinkler systems and construction deficiencies appearing in three separate inspections. While the provider reports correcting all deficiencies, the pattern of recurring violations in critical care areas warrants careful consideration during your visit.

Dec 8, 2025Complaint
1
0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Jun 26, 2025Routine
11
0161Potential for harm · WidespreadCorrected

Construction Deficiencies

Use approved construction type or materials.

0657Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0679Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

0567Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0690Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0697Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0699Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

0271Potential for harm · IsolatedCorrected

Egress Deficiencies

Have exits that are accessible at all times.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Jun 26, 2025Complaint
3
0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0725Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Aug 8, 2024Routine
3
0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0161Potential for harm · PatternCorrected

Construction Deficiencies

Use approved construction type or materials.

0511Potential for harm · PatternCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Dec 7, 2023Routine
10
0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0758Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0222Potential for harm · IsolatedCorrected

Egress Deficiencies

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.

0311Potential for harm · IsolatedCorrected

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

0345Potential for harm · IsolatedCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0511Potential for harm · IsolatedCorrected

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Dec 7, 2023Complaint
1
0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Federal Penalties

Fine

Dec 11, 2023

$10,489

State Inspection History

State Inspections

Source: Iowa Dept. of Inspections, Appeals & Licensing

10total
21deficiencies
Dec 15, 2025Complaint
Clean

Fed violations: 0, State violations: 0

Dec 8, 2025Complaint
Clean

Fed violations: 1, State violations: 0

Jul 26, 2025Inspection
Clean

Fed violations: 0, State violations: 0

Jun 26, 2025Inspection
Clean

Fed violations: 11, State violations: 0

Aug 8, 2024Inspection
Clean

Fed violations: 0, State violations: 0

Jan 7, 2024Inspection
Clean

Fed violations: 0, State violations: 0

Dec 7, 2023Inspection
Clean

Fed violations: 4, State violations: 0

Sep 8, 2022Inspection
Clean

Fed violations: 0, State violations: 0

Ownership & Operations

Who Operates This Facility

Owner / Operator

Crystal Heights Care Center

Organization Type

for profit

Chain Affiliation

Chain Name

The Ensign Group

Chain Size

342 facilities nationwide

Ownership & Management

Owners

Gateway Healthcare LLC

Owner · Organization

The Ensign Group INC

Owner (parent company) · Organization

Jorgensen, David

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Keetch, Chad

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Port, Barry

Individual is an Owner, Partner or Trustee of Any Adp of the Snf

Key personnel

Burnam, SoonManaging Control - Governing BodyKoenig, DebraManaging Control - Governing BodyNorth, DavidManaging Control - Governing BodyBurnam, SoonManagerKoenig, DebraManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 4 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

Call