Crystal Heights Care Center in Oskaloosa, IA has a 1-star overall rating, with a 1-star staffing rating and nurse staffing below the federal benchmark (2.94 vs. 4.1 hours per resident per day). It has no fines in the last 24 months, but it is flagged for the lowest overall rating and recent inspection citations included care planning, resident activities, and medication error concerns.
Last inspection: December 8, 2025Penalties, last 24 months: $0lowest overall rating
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 2.9377.
Staffing detail
Registered nurses
0.34
Licensed practical nurses
0.49
Nurse aides
2.11
Weekend nursing
2.51
Hours per resident per day.
Total staff turnover: 64%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Last yrNowTrend
Long-stay residents on antipsychotic medication
31.9%34.7%Worsening
Residents with a fall causing major injury
0%3.1%Worsening
Residents with pressure ulcers (bedsores)
0%1.5%Worsening
Residents with a urinary tract infection
20%6.3%Improving
Residents who lost too much weight
10.3%8.8%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
7.1%21.8%Worsening
Residents whose ability to walk got worse
10.8%20.7%Worsening
Long-stay residents on antianxiety or sleep medication
19%20.7%Worsening
Short-stay residents newly given an antipsychotic
—0%—
Residents with a long-term catheter
5.9%0%Improving
Residents with new or worsening incontinence
4.9%25.5%Worsening
Residents with depressive symptoms
12.7%0%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Last yrNowTrend
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
100%89.1%Worsening
Short-stay residents given the pneumonia vaccine
—57.1%—
What the inspectors found
The home failed to complete and keep the resident’s care plan properly prepared, reviewed, and updated by the right health professionals. Cited June 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 657 — 42 CFR §483.21(b)(2) — S/S: E
The home failed to provide activities that met all residents’ needs. Cited June 2025 — limited pattern, potential for harm.
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F-Tag 679 — 42 CFR §483.24 — S/S: E
The nursing home failed to ensure residents were free from significant medication errors. Cited December 2025 — isolated incident, potential for harm.
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F-Tag 760 — 42 CFR §483.45(f)(2) — S/S: D
The nursing home failed to honor a resident’s right to manage their own money and financial affairs. Cited June 2025 — isolated incident, potential for harm.
View the original federal record
F-Tag 567 — 42 CFR §483.10 — S/S: D
The home failed to honor residents’ choices about treatment, research participation, and advance care instructions. Cited June 2025 — isolated incident, potential for harm.
View the original federal record
F-Tag 578 — 42 CFR §483.10 — S/S: D
Recent history
STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
INSPECTION
Health inspection found 11 health deficiencies.
See what inspectors found
INSPECTION
Health inspection found 4 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $10,489 in total fines.
Federal fine
Dec 11, 2023
$10,489
Operator & ownership
Ownership
For profit - Corporation
Chain
Part of THE ENSIGN GROUP · 338 homes · 3.2 stars avg
Occupancy
67.1 residents on an average day (93% of 72 beds)
Resident voice
Resident & family councils
Medicare history
Certified for 20 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.