Inspection Reports for Crystal Heights Care Center
1514 High Avenue West, IA, 525771997
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 15, 2025, found the facility in substantial compliance with no deficiencies cited. Earlier inspections showed a pattern of deficiencies related primarily to medication administration errors, resident care planning, and infection control. Complaint investigations included a substantiated medication error in December 2025 that resulted in resident harm, as well as prior findings involving resident dignity, pain management, and staffing levels. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement over time, with the most recent survey indicating resolution of prior issues.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
70 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 15, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status.
Findings
Based on acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, the facility will be certified in compliance effective December 15, 2025.
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 1
Dec 8, 2025
Visit Reason
The inspection was conducted as a result of investigation of Complaints #2670073-C and Facility Reported Incident #2680954-I from December 2 to December 8, 2025.
Findings
A deficiency was cited related to medication administration errors involving Resident #1, including a medication error with Enoxaparin and Glucagon syringes being incorrectly placed and administered, resulting in a hypoglycemic episode. Staff education and corrective actions were planned and initiated.
Complaint Details
The visit was complaint-related involving Complaints #2670073-C and Facility Reported Incident #2680954-I. The deficiency was substantiated as evidenced by medication errors and resident harm.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents are free of significant medication errors; facility failed to follow medication administration protocol resulting in wrong medication being administered to Resident #1. | SS = D |
Report Facts
Census: 70
Complaint numbers: 2
Medication units: 26
Dates: Nov 26, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Involved in medication administration and error reporting |
| Director of Nursing | DON | Interviewed regarding medication error and resident care |
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 26, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's compliance status, indicating acceptance of a credible allegation of substantial compliance and certification of compliance effective July 26, 2025.
Findings
The facility was found to be in substantial compliance based on the accepted plan of correction, resulting in certification of compliance effective July 26, 2025. No specific deficiencies are detailed in the report.
Inspection Report
Annual Inspection
Census: 62
Deficiencies: 10
Jun 26, 2025
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of Complaint #127387-C, along with a Facility Reported Incident #127401-I, conducted from June 23, 2025 to June 26, 2025.
Findings
The facility was found deficient in multiple areas including resident rights, management of personal funds, advance directives, accuracy of assessments, comprehensive care plans, activities, pain management, trauma-informed care, sufficient nursing staff, and infection control. Several residents were noted to have unmet needs or improper care related to dignity, toileting assistance, pain management, and trauma-informed care. The facility lacked certain policies and failed to ensure consistent documentation and care conference practices.
Complaint Details
Complaint #127387-C resulted in a deficiency related to resident dignity and respect issues, including failure to assist residents to the bathroom and acknowledge food preferences.
Severity Breakdown
SS=D: 8
SS=E: 2
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to treat residents with dignity and respect, including failure to assist residents to the bathroom and acknowledge food temperature preferences. | SS=D |
| Facility failed to ensure residents had ready access to their personal funds. | SS=D |
| Facility failed to ensure consistent documentation of code status and advance directives for residents. | SS=D |
| Facility failed to ensure staff completed accurate assessments reflecting residents' status. | SS=D |
| Facility failed to ensure comprehensive care plans were developed and updated for residents, including hospice services and behavioral interventions. | SS=E |
| Facility failed to provide activities meeting residents' interests and needs, especially in the dementia unit. | SS=E |
| Facility failed to provide adequate pain management for residents. | SS=D |
| Facility failed to provide trauma-informed care for residents who were trauma survivors. | SS=D |
| Facility failed to provide sufficient nursing staff to meet residents' needs. | SS=D |
| Facility failed to maintain an effective infection prevention and control program, including sanitizing medication preparation areas and hand hygiene. | SS=D |
Report Facts
Census: 62
Residents reviewed for dignity: 5
Residents reviewed for personal funds access: 1
Residents reviewed for advance directives: 24
Residents reviewed for assessment accuracy: 19
Residents reviewed for comprehensive care plans: 7
Residents reviewed for activities: 15
Residents reviewed for pain management: 1
Residents reviewed for trauma-informed care: 2
Residents reviewed for sufficient nursing staff: 19
Residents reviewed for infection prevention: 62
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Reported observations related to resident dignity and toileting assistance. |
| Staff D | Certified Nursing Assistant (CNA) | Involved in resident toileting assistance and behavior observations. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Provided statements on facility policies, care plan updates, and monitoring compliance. |
| Staff F | Registered Nurse (RN) | Reported knowledge of residents and pain management observations. |
| Staff K | Certified Nursing Assistant (CNA) | Reported on use of Hoyer lift and resident transfers. |
| Staff I | Certified Nursing Assistant (CNA) | Fed resident and reported on resident's refusal to eat and toileting needs. |
| Staff J | Certified Nursing Assistant (CNA) | Fed resident and communicated with other staff about toileting. |
| Business Office Manager (BOM) | Business Office Manager | Reported on resident trust fund policy and activity calendar. |
| Staff N | Certified Nursing Assistant (CNA) | Reported familiarity with trauma survivor resident. |
| Staff B | Registered Nurse (RN) | Observed medication administration and infection control issues. |
| Staff C | Certified Nursing Assistant (CNA) | Reported on resident shower refusals and staffing issues. |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 8, 2024
Visit Reason
An Annual Recertification survey was conducted from August 5, 2024 to August 8, 2024.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 7, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and demonstrate substantial compliance for certification.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective January 7, 2024.
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 4
Dec 7, 2023
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification survey and investigation of Complaints #116880-C and Facility Reported Incidents #117226-I from December 4 to December 7, 2023.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans for residents, unsafe medication administration practices, inadequate monitoring of personal care leading to skin breakdown, and failure to properly re-evaluate psychotropic medications with gradual dose reductions as required.
Complaint Details
The inspection included investigation of Complaints #116880-C and Facility Reported Incidents #117226-I.
Severity Breakdown
SS=D: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to develop and implement a comprehensive care plan for 2 of 2 residents reviewed (Resident #50 and Resident #54). | SS=D |
| Failed to safely transport prepared insulin needles from medication cart to residents for 2 of 3 residents observed (Resident #34, #40). | SS=D |
| Failed to monitor completion of personal cares resulting in skin breakdown for 1 of 2 residents reviewed (Resident #35). | SS=D |
| Failed to re-evaluate psychotropic and antidepressant medications with gradual dose reductions for 3 of 5 residents reviewed (Resident #9, #10, #28). | SS=D |
Report Facts
Resident census: 55
Residents reviewed for care plan deficiency: 2
Residents observed for insulin administration: 3
Residents reviewed for personal care deficiency: 2
Residents reviewed for psychotropic medication re-evaluation: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed care plans had not been developed and acknowledged failure to complete gradual dose reduction requests for antidepressants. |
| Staff A | Licensed Practical Nurse (LPN) | Observed transporting insulin needles without sheath for Residents #34 and #40. |
| Director of Nursing | Director of Nursing (DON) | Reported expectation for nursing staff to use needle sheaths during transport and confirmed documentation failures related to resident care refusals. |
| Staff C | Certified Nursing Assistant (CNA) | Reported Resident #35 independent for all cares except bathing and unaware of skin redness. |
| Staff D | Certified Nursing Assistant (CNA) | Reported Resident #35 is 1/2 independent and 1/2 assisted with bathing and peri cares. |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 8, 2022
Visit Reason
The document serves as a statement of deficiencies and plan of correction for Crystal Heights Care Center, certifying compliance based on acceptance of a credible allegation of compliance and plan of correction.
Findings
The facility was certified in compliance effective September 8, 2022, based on acceptance of the credible allegation of compliance and plan of correction. No specific deficiencies are detailed in this document.
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 5
Jul 28, 2022
Visit Reason
The inspection was conducted as an annual recertification survey of Crystal Heights Care Center from July 25, 2022 to July 28, 2022.
Findings
The facility was found deficient in several areas including failure to notify the State Ombudsman of hospital transfers, incomplete and untimely Minimum Data Set (MDS) assessments, failure to update care plans after changes in resident condition, and incomplete discharge summaries. The facility reported a census of 54 residents during the survey.
Deficiencies (5)
| Description |
|---|
| Failure to notify the State Ombudsman of hospital transfers for 1 of 3 residents reviewed. |
| Failure to complete an Annual Minimum Data Set (MDS) assessment in a timely manner for 1 resident. |
| Failure to complete quarterly review assessments timely for 5 of 5 residents reviewed. |
| Failure to update care plans after a change in condition for 2 of 2 residents reviewed. |
| Failure to complete a discharge summary that included a summary of the resident's stay for 1 of 1 discharged resident. |
Report Facts
Deficiencies cited: 5
Census: 54
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Reported on MDS nurse walking out and care plan issues; interviewed regarding deficiencies. |
| Business Office Manager | Business Office Manager | Interviewed regarding hospital transfer notifications and related deficiencies. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding facility policies on ombudsman notifications and care plan reviews. |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 7
Aug 9, 2021
Visit Reason
The inspection was conducted in response to Complaint #95105 related to allegations of abuse, neglect, exploitation, or mistreatment involving Resident #3's missing personal possessions.
Findings
The facility failed to report an allegation of abuse to the State Agency within 24 hours for Resident #3 who had missing personal possessions. The complaint was not substantiated. Additionally, the facility failed to conduct a thorough investigation of the abuse allegation and failed to utilize the services of a Registered Nurse for required hours.
Complaint Details
Complaint #95105-C was investigated and found not substantiated. The facility failed to report the allegation of abuse within 24 hours and failed to conduct a thorough investigation. Resident #3 reported missing wallet and money; facility replaced wallet and money but did not report to State Agency timely.
Severity Breakdown
SS=D: 5
SS=E: 3
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to report an allegation of abuse to the State Agency within 24 hours for Resident #3's missing personal possessions. | SS=D |
| Failed to conduct a thorough investigation of the abuse allegation for Resident #3. | SS=D |
| Failed to utilize the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. | SS=E |
| Failed to remove expired medications from the medication storage room for 5 of 5 medications observed. | SS=D |
| Failed to ensure all medication storage rooms and carts were free of expired medications. | SS=D |
| Failed to ensure food was stored, prepared, and served under sanitary conditions; observed chips in dishes and unclean steam table. | SS=E |
| Failed to maintain toilet seats and bed control/call light cords in safe and operating condition. | SS=D |
Report Facts
Resident census: 53
RN staffing hours missed: 8
Expired medications: 5
Influenza vaccine boxes removed: 4
Meal service plates served: 16
Resident count on mechanical soft diet: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Named as grievance officer and involved in investigation of Resident #3's missing money |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding missing wallet incident and investigation |
| Director of Nursing | Director of Nursing (DON) | Reported on RN staffing and medication storage monitoring |
| Staff B | Certified Nurse Aide | Provided examples of abuse and reported training |
| Staff A | Certified Nurse Aide | Reported abuse training and reporting procedures |
| Staff C | Housekeeper | Reported abuse training and reporting procedures |
| Dietary Manager | Dietary Manager | Reported training, certification status, and food service observations |
| Maintenance Supervisor | Maintenance Supervisor | Replaced toilet seats, doorknobs, call lights, and bed controls |
| Maintenance Director | Maintenance Director | Reported maintenance activities and documentation |
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 3
Jun 1, 2020
Visit Reason
The inspection was conducted as a COVID-19 Focused Infection Control Survey and Complaint #91250-A by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 prevention.
Findings
The facility failed to complete annual performance evaluations for nurse aides and did not implement an effective screening process for staff and visitors to prevent COVID-19 spread, resulting in an outbreak with 9 deaths. Additionally, the facility failed to provide required in-service training hours for nurse aides.
Complaint Details
Complaint #91250-A was investigated related to COVID-19 infection control practices. The facility was not found in substantial compliance with CMS and CDC recommended practices. The complaint was substantiated by findings of ineffective screening and training.
Deficiencies (3)
| Description |
|---|
| Failed to complete an annual performance evaluation for 10 of 10 Nurse Aide personnel files reviewed. |
| Failed to implement and monitor an effective screening process for staff and visitors to prevent COVID-19 outbreak affecting 56 of 74 residents. |
| Failed to provide 12 hours of in-service training per year for 8 of 10 Nurse Aide personnel files reviewed. |
Report Facts
Census: 68
Residents affected by COVID-19 outbreak: 56
Resident deaths: 9
Nurse Aide personnel files reviewed: 10
Nurse Aide personnel files lacking required training: 8
Residents tested for COVID-19: 49
Staff tested for COVID-19: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Named in findings related to working while ill and COVID-19 positive |
| Director of Nurses | Provided statements regarding lack of annual performance evaluations and COVID-19 screening | |
| Assistant Director of Nurses | Reported on Staff A's COVID-19 test and work attendance | |
| Administrator | Provided information on staff work schedules and sick calls |
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