Crystal Heights Care Center — nursing home in Oskaloosa, IA

Facility type: Nursing home · SNF / NF
CMS provider type: Medicare and Medicaid
Certified beds: 72 CMS-certified beds (not state-licensed beds)
Licensed beds: State licensure is issued by the state survey agency. State license records are not yet ingested for this facility; the federal CMS certification is shown instead.
Average residents per day: 66.9 CMS, MDS-derived
CMS Certification Number: 165570
Certification status: Active CMS certification Verified
First approved (Medicare/Medicaid): Jun 1, 2006
Ownership type: For profit - Corporation
Operator (legal business name): Canfield River Healthcare LLC
CMS chain: The Ensign Group 347 facilities
Phone: (641) 673-7032
Resident & family council: Resident
Sprinklers in all required areas: Yes
Official profile: Medicare Care Compare ↗

Inspection record · CMS window

Verified

Inspections

9

latest Aug 20, 2026

Citations

32

20 health · 12 fire

Harm or worse

1

no immediate jeopardy

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J·	K·	L·
Actual harm	G1	H·	I·
Potential harm	D18	E8	F5
Minimal	A·	B·	C·

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

CMS Five-Star ratings

Federal · CMS

Overall

Health inspections

Staffing

Quality measures

Penalties · about the last 3 years

Fines

1

$10,489

Payment denials

0

Latest

Dec 11, 2023

Federal certification

Federal · CMS

Authority: Centers for Medicare & Medicaid Services (CMS), surveyed by the state survey agency
CCN: 165570
Program: Medicare and Medicaid
Medicare (SNF): Certified
Medicaid (NF): Certified
Certified beds: 72
First approved: Jun 1, 2006
Located in a hospital: No
Status: Active CMS certification as of CMS release Oct 1, 2026
Evidence: Verified

State license

State licensure is issued by the state survey agency. State license records are not yet ingested for this facility; the federal CMS certification is shown instead. State coverage for Iowa.

Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

Date	Domain	Survey types	Citations	Most severe	Open
Aug 20, 2026	Health	Health Complaint	2	Potential harm	—	Open →
Jul 16, 2026	Fire safety	Fire Safety Standard	6	Potential harm	—	Open →
Jul 16, 2026	Health	Health Standard	5	Actual harm	—	Open →
Dec 8, 2025	Health	Health Complaint	1	Potential harm	—	Open →
Jun 26, 2025	Fire safety	Fire Safety Standard	3	Potential harm	—	Open →
Jun 26, 2025	Health	Health Complaint, Health Standard	11	Potential harm	—	Open →
Aug 8, 2024	Fire safety	Fire Safety Standard	3	Potential harm	—	Open →
Aug 8, 2024	Health	Health Standard	0	No citations	—	Open →
Dec 7, 2023	Health	Health Complaint	1	Potential harm	—	Open →

Enforcement

Penalties

Civil money penalties and denials of payment for new admissions, as published by CMS (about the last three years). Amounts may change on appeal.

Date	Type	Amount	Payment denial	Record
Dec 11, 2023	Civil money penalty (fine)	$10,489	—	165570\|Fine\|79130

Scope × severity

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J·	K·	L·
Actual harm	G1	H·	I·
Potential harm	D18	E8	F5
Minimal	A·	B·	C·

By concept

Date	Tag	Deficiency	Scope / severity	Correction	Flags
Aug 20, 2026	F-0658	Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Sep 1, 2026	Complaint
Aug 20, 2026	F-0690	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Sep 1, 2026	Complaint
Jul 16, 2026	F-0688	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. Quality of Life and Care Deficiencies · Clinical care	G · Actual harm Isolated	Corrected Aug 6, 2026	IDR
Jul 16, 2026	E-0039	Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness	F · Potential harm Widespread	Corrected Jul 29, 2026
Jul 16, 2026	K-0222	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. Egress Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jul 27, 2026
Jul 16, 2026	K-0324	Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Jul 17, 2026
Jul 16, 2026	K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jul 21, 2026
Jul 16, 2026	K-0712	Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Jul 28, 2026
Jul 16, 2026	K-0923	Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jul 17, 2026
Jul 16, 2026	F-0567	Honor the resident's right to manage his or her financial affairs. Resident Rights Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Aug 6, 2026
Jul 16, 2026	F-0679	Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Aug 6, 2026
Jul 16, 2026	F-0809	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. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	E · Potential harm Pattern	Corrected Aug 6, 2026
Jul 16, 2026	F-0865	Have a plan that describes the process for conducting QAPI and QAA activities. Administration Deficiencies · Administration & records	D · Potential harm Isolated	Corrected Aug 6, 2026
Dec 8, 2025	F-0760	Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management	D · Potential harm Isolated	Corrected Dec 15, 2025	Complaint
Jun 26, 2025	K-0161	Use approved construction type or materials. Construction Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Jul 22, 2025
Jun 26, 2025	K-0271	Have exits that are accessible at all times. Egress Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Jul 22, 2025
Jun 26, 2025	K-0353	Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Jul 22, 2025
Jun 26, 2025	F-0550	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Jul 26, 2025	Complaint
Jun 26, 2025	F-0567	Honor the resident's right to manage his or her financial affairs. Resident Rights Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Jul 26, 2025
Jun 26, 2025	F-0578	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. Resident Rights Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Jul 26, 2025
Jun 26, 2025	F-0641	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jul 26, 2025
Jun 26, 2025	F-0657	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care	E · Potential harm Pattern	Corrected Jul 26, 2025
Jun 26, 2025	F-0679	Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care	E · Potential harm Pattern	Corrected Jul 26, 2025
Jun 26, 2025	F-0690	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jul 26, 2025
Jun 26, 2025	F-0697	Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jul 26, 2025
Jun 26, 2025	F-0699	Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jul 26, 2025
Jun 26, 2025	F-0725	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision	D · Potential harm Isolated	Corrected Jul 26, 2025	Complaint
Jun 26, 2025	F-0880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention	D · Potential harm Isolated	Corrected Jul 26, 2025	Complaint
Aug 8, 2024	K-0161	Use approved construction type or materials. Construction Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Aug 21, 2024
Aug 8, 2024	K-0353	Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Sep 15, 2024
Aug 8, 2024	K-0511	Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Aug 22, 2024
Dec 7, 2023	F-0656	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jan 7, 2024	Complaint

“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.

Five-Star ratings

Federal · CMS

Overallstate 3.1

Health inspectionsstate 2.8

Staffingstate 3.8

Quality measuresstate 3.4

Long-stay QM

Short-stay QM

CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.

Nurse staffing · hours per resident per day

Total nurse staffing3.07

State avg 3.86US avg 3.90

Registered nurse (RN)0.41

State avg 0.74US avg 0.69

Licensed practical nurse0.46

State avg 0.56US avg 0.86

Nurse aide2.20

State avg 2.56US avg 2.35

Weekend total nurse2.55

State avg 3.38US avg 3.43

Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 3.69 (case-mix index 1.16).

Staff turnover

Total nursing staff turnover56.6%

State avg 44.1%US avg 45.3%

Registered nurse turnoverNot reported

State avg 42.1%US avg 42.5%

Administrators who left1

State avg 0US avg 1

Health survey score

Cycle 1 standard survey: Jul 16, 2026
Cycle 1 health score: 32
Total weighted score: 38

Operating entity

Canfield River Healthcare LLC

CMS legal business name of the certified provider. Operates this facility only.

VerifiedLinked by exact legal name

CMS chain

The Ensign Group

347 facilities in 17 states. CMS chain ID 507.

VerifiedAssigned by CMS

Chain average overall rating (CMS): 3.3

Ownership disclosures

Disclosures

16

Organizations

5

Individuals

11

Direct & indirect ownership

Owners of record

Name	Type	Role (Carefield group)	CMS role text	Share	Since
Gateway Healthcare LLC	Organization	Direct owner	DIRECT OWNERSHIP INTEREST	not provided	May 21, 2025
The Ensign Group Inc	Organization	Indirect owner	INDIRECT OWNERSHIP INTEREST	not provided	May 21, 2025

CMS Ownership file

All disclosed roles

Operator, owners, managers, officers and lenders are distinct roles and are never flattened into one entity. Organizations link across facilities by exact normalized legal name; individuals are listed per facility only.

Name	Type	Role (Carefield group)	CMS role text	Share	Since
Gateway Healthcare LLC	Organization	Direct owner	DIRECT OWNERSHIP INTEREST	not provided	May 21, 2025
The Ensign Group Inc	Organization	Indirect owner	INDIRECT OWNERSHIP INTEREST	not provided	May 21, 2025
David Jorgensen	Individual	Partner	INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF	not provided	Aug 20, 2025
Chad Keetch	Individual	Partner	INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF	not provided	Aug 20, 2025
Barry Port	Individual	Partner	INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF	not provided	Jul 24, 2025
Soon Burnam	Individual	Operational / managerial control	MANAGING CONTROL - GOVERNING BODY	not provided	May 21, 2025
Debra Koenig	Individual	Operational / managerial control	MANAGING CONTROL - GOVERNING BODY	not provided	Aug 1, 2025
David North	Individual	Operational / managerial control	MANAGING CONTROL - GOVERNING BODY	not provided	Aug 1, 2025
Soon Burnam	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	May 21, 2025
Debra Koenig	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Aug 1, 2025
David North	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Aug 1, 2025
Ensign Services Inc	Organization	Additional disclosable party	ADP OF THE SNF	not provided	May 21, 2025
Narrows Peak Health Holdings LLC	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Aug 1, 2025
Standard Bearer Healthcare Op, LP	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Aug 1, 2025
Debra Koenig	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Jul 24, 2025
David North	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Jul 24, 2025

Same chain in Iowa

All 346 in chain →

Facility	Beds	Last inspection	Citations (window)	Fines
Fort Dodge Health and Rehabilitation 728 14th Avenue North, Fort Dodge, IA 50501 CCN 165156	65	Feb 26, 2026	631 IJ5 harm	$166k
Greater Southside Health and Rehabilitation 5608 SW 9th Street, Des Moines, IA 50315 CCN 165175SFF CandidateAbuse icon	80	Jul 22, 2026	925 IJ3 harm13 open	$223k
Hillcrest Health Care Center 2121 Avenue L, Hawarden, IA 51023 CCN 165245Abuse icon	64	May 6, 2026	962 IJ1 harm	$94k
Rehabilitation Center of Des Moines 701 Riverview, Des Moines, IA 50316 CCN 165268	74	Aug 27, 2026	531 harm2 open	—
Clarion Wellness and Rehabilitation Center 110 13th Avenue SW, Clarion, IA 50525 CCN 165362	76	Nov 25, 2025	534 IJ	$24k
Careage Hills Rehabilitation and Healthcare 725 North Second Street, Cherokee, IA 51012 CCN 165428	44	Mar 5, 2026	202 harm	—
West Bend Health and Rehabilitation 203 Fourth Street NW, West Bend, IA 50597 CCN 165444	45	Jun 25, 2026	26	—
Spencer Post Acute Rehabilitation Center 711 West 11th Street, Spencer, IA 51301 CCN 165449	82	Jun 4, 2026	812 IJ1 harm	$25k

No building or property record is linked to this facility yet. Parcel, assessor and building-permit joins will be added only where a valid site match exists.

Coordinates as published by CMS.

Address: 1514 High Avenue West, Oskaloosa, IA 52577
ZIP: 52577
County: Mahaska County FIPS 19123
State: Iowa
Urban / rural (CMS): Rural

Within ~25 km

Nearby nursing homes

Facility	Distance	Beds	CMS overall	Last inspection	Citations (window)	Fines
Oskaloosa Care Center 605 Highway 432, Oskaloosa, IA 52577 CCN 165589	0.7 km	83		Jul 30, 2026	481 IJ1 harm	$45k
Northern Mahaska Specialty Care 2401 Crestview Drive, Oskaloosa, IA 52577 CCN 165274	2.6 km	79		Nov 24, 2025	251 IJ	$39k

Source	Record	Facts	Evidence	Source release	Retrieved
CMS Provider Information US-CMS	165570	name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain	Verified	Oct 1, 2026	Nov 7, 2026
CMS Provider Information US-CMS	165570	ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only.	Verified	Oct 1, 2026	Nov 7, 2026

Record-level source links for CCN 165570

First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction