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Nursing homeFAID #4429

Crystal Heights Care Center

1514 HIGH AVENUE WEST, OSKALOOSA, IA, 52577
(641) 673-7032
ensignservices.net
72 licensed beds
★★★★★2/5CMS Five-Star overall2/5 health inspections2/5 staffing2/5 quality measuresSource: CMS Care Compare

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Public record summary

What we can show you for free.
Bed capacity
72
CMS facility ID
165570
Care type
Nursing home
County
Mahaska
Facility name
Crystal Heights Care Center
Street address
1514 HIGH AVENUE WEST
City / state / ZIP
Oskaloosa, IA 52577
Phone
(641) 673-7032
Website
ensignservices.net

About this facility — Crystal Heights Care Center

Crystal Heights Care Center is a Medicare/Medicaid-certified skilled nursing facility in Oskaloosa, Iowa. It is licensed for 72 beds — above the median for skilled nursing facilities in Iowa (57 beds).

It is one of 7 senior care facilities in Oskaloosa and 389 skilled nursing facilities across Iowa. Families comparing options should weigh inspection history, ownership record, and litigation — not just the tour — before deciding.

Federal inspectors have cited Crystal Heights Care Center 29 times across 9 inspections in the last three years, and CMS has imposed $10,489 in fines. Every citation is listed, dated, and graded in the inspection record below.

This listing draws on federal CMS Nursing Home Compare records, and was last updated on August 31, 2026. Background reports are compiled from primary sources — state inspection files, federal CMS data, corporate registrations, and court records — at the time of order.

Facility background

What the public record shows.

Ownership & operator

Parent company
The Ensign Group
Ownership type
For profit - Corporation

Registered owners & officers

Burnam, Soon
Governing body · Operational control — since 2025
Ensign Services Inc
Additional disclosable party — since 2025
Gateway Healthcare Llc
Direct owner — since 2025
Jorgensen, David
Owner of a disclosable party — since 2025
Keetch, Chad
Owner of a disclosable party — since 2025
Koenig, Debra
Governing body · Operational control · Additional disclosable party — since 2025
Narrows Peak Health Holdings Llc
Additional disclosable party — since 2025
North, David
Governing body · Operational control · Additional disclosable party — since 2025
Port, Barry
Owner of a disclosable party — since 2025
Standard Bearer Healthcare Op, Lp
Additional disclosable party — since 2025
The Ensign Group Inc
Indirect owner — since 2025

Regulatory standing

Federal court records
11 naming its parent company — view the cases (a listed case is not a finding of wrongdoing)
Licensed / certified since
2006-06-01
CMS overall rating
2 of 5 stars
Health deficiencies
12 at the last standard inspection
Federal fines
$10,489 total
Last standard inspection
2025-06-26
Nurse staffing
3.1 hours per resident per day

Cost & payer profile (FY2023 cost report)

Average billed charges
$228 per day (≈ $6,930/month). Private-pay prices typically track billed charges; Medicare and Medicaid pay set rates.
Payer mix (resident days)
80% Medicaid · 2% Medicare · 18% private/other
Occupancy
55% (fiscal year 2023)
Vs. state median
33% below the IA median of $342/day — full state cost breakdown

Services & coverage

Licensed beds
72
Medicare
Accepted
Medicaid
Accepted
Compiled from CMS Nursing Home Compare; owners/officers from the CMS Ownership dataset; cost & occupancy from the facility's own CMS cost report · last verified 2026-08-31. Facilities can submit a correction.

Inspection record

Every citation, dated and graded.

Kitchen & food safety

CleanNo food-safety or dietary citations in the last three years of federal inspections.
2025-12-08Health inspectionComplaint-triggered1 citation
F-0760
D · No harm foundFrom a complaint
Ensure that residents are free from significant medication errors.
Corrected 2025-12-15
2025-06-26Health inspectionComplaint-triggered11 citations
F-0550
D · No harm foundFrom a complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-07-26
F-0567
D · No harm found
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-07-26
F-0578
D · No harm found
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 2025-07-26
F-0641
D · No harm found
Ensure each resident receives an accurate assessment.
Corrected 2025-07-26
F-0657
E · No harm found
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-07-26
F-0679
E · No harm found
Provide activities to meet all resident's needs.
Corrected 2025-07-26
F-0690
D · No harm found
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 2025-07-26
F-0697
D · No harm found
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-26
F-0699
D · No harm found
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-07-26
F-0725
D · No harm foundFrom a 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 2025-07-26
F-0880
D · No harm foundFrom a complaint
Provide and implement an infection prevention and control program.
Corrected 2025-07-26
4 earlier / fire-safety inspections (17 citations)
2023-12-07Health inspectionComplaint-triggered4 citations
F-0656
D · No harm foundFrom a complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-07
F-0658
D · No harm found
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-07
F-0677
D · No harm found
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-01-07
F-0758
D · No harm found
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 2024-01-07
2025-06-26Fire-safety inspection3 citations
K-0161
F · No harm found
Use approved construction type or materials.
Corrected 2025-07-22
K-0271
D · No harm found
Have exits that are accessible at all times.
Corrected 2025-07-22
K-0353
D · No harm found
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-22
2024-08-08Fire-safety inspection3 citations
K-0161
E · No harm found
Use approved construction type or materials.
Corrected 2024-08-21
K-0353
F · No harm found
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-15
K-0511
E · No harm found
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-22
2023-12-07Fire-safety inspection7 citations
K-0222
D · No harm found
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.
Corrected 2023-12-19
K-0311
D · No harm found
Have an enclosure around a vertical opening shaft.
Corrected 2023-12-13
K-0345
D · No harm found
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-28
K-0353
E · No harm found
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-14
K-0363
D · No harm found
Install corridor and hallway doors that block smoke.
Corrected 2023-12-12
K-0511
D · No harm found
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-15
K-0920
D · No harm found
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-15

Federal penalties

2023-12-11Fine$10,489
Citations and penalties from the CMS Provider Data Catalog (three-year survey window, refreshed monthly). Severity codes follow the federal scope/severity grid; “Immediate jeopardy” is the most serious grade CMS issues. CCN 165570.

Inside your report

What unlocks when you order.

Ownership & corporate history

Primary tier
Prior operators & transfers
Corporate network & affiliates
,
Owners' other facilities
· · 2 more

Inspection citations — last 5 years

Locked
The 29 citations above are shown free. The report takes each one and explains it in plain English — what the tag requires, how serious the scope/severity grade really is, whether it recurred across surveys — plus the five-year pattern a single inspection can't show.

Civil & criminal lawsuits

Advanced tier only
Active civil suits
#
Federal dockets
CDC infection data
Unlock the full file
Citations, owner history, lawsuits — decoded into one PDF.
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Original records

Sources we pull for this facility.
Source
CMS Nursing Home Compare
data.cms.gov Provider Data Catalog
Last verified 2026-08-31
Source
Secretary of State filings
Entity & officer search
Pulled when a report is ordered
Source
PACER federal dockets
pacer.uscourts.gov
Pulled when a report is ordered