Inspection Reports for
Crystal Heights Care Center
1514 High Avenue West, Oskaloosa, IA, 525771997
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
5.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
20% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
97% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: Dec 8, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a medication administration error involving Resident #1.
Complaint Details
The complaint investigation found that Resident #1 was administered Enoxaparin instead of Glucagon during a hypoglycemic episode due to pharmacy error in medication placement. Resident #1's blood sugars were critically low, and emergency medical services were called. The error was substantiated.
Findings
The facility failed to follow medication administration protocol resulting in the wrong medication, Enoxaparin, being administered instead of Glucagon to Resident #1 during a hypoglycemic episode. The pharmacy had incorrectly placed Enoxaparin syringes in the Glucagon compartment and vice versa.
Deficiencies (1)
Failure to follow medication administration protocol resulting in wrong medication administered to Resident #1.
Report Facts
Medication dosage: 26
Blood sugar level: 38
Blood sugar level: 36
Medication dosage: 100
Census: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Registered Nurse | Administered incorrect medication to Resident #1 and reported the error |
| Director of Nursing | Questioned regarding the medication error incident |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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: 11
Date: Jun 26, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided at Crystal Heights Care Center.
Findings
The facility was found deficient in multiple areas including failure to respect residents' dignity, inadequate access to personal funds, inconsistent documentation of code status, inaccurate resident assessments, incomplete care plans, insufficient activity programs for residents with dementia, failure to assist residents with toileting needs, inadequate pain management, lack of trauma-informed care for trauma survivors, insufficient nursing staff to meet resident needs, and lapses in infection prevention practices during medication administration.
Deficiencies (11)
Failed to treat residents with dignity by not assisting residents to the bathroom when needed and not acknowledging food temperature preferences.
Failed to ensure residents had ready access to their personal funds.
Failed to ensure consistent documentation of code status for residents receiving hospice care.
Failed to ensure accurate resident assessments reflecting true functional status.
Failed to develop complete care plans reflecting hospice services, transfer status, activities, and behavioral interventions.
Failed to provide adequate activity programs meeting the needs of residents with dementia and cognitive impairments.
Failed to assist residents to the bathroom when the need was voiced.
Failed to provide appropriate pain management and documentation for a resident with pain.
Failed to provide trauma-informed care for residents identified as trauma survivors.
Failed to provide sufficient nursing staff to meet resident needs, resulting in delayed showers and delayed response to call lights.
Failed to implement infection prevention practices during medication administration, including failure to sanitize insulin vial stoppers and failure to perform hand hygiene between residents.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 7
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 4
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in dignity and trauma-informed care findings |
| Staff D | Certified Nursing Assistant (CNA) | Named in dignity findings related to toileting assistance |
| Staff F | Registered Nurse (RN) | Named in assessment and infection control findings |
| Staff I | Certified Nursing Assistant (CNA) | Named in toileting and pain management findings |
| Staff J | Certified Nursing Assistant (CNA) | Named in toileting findings |
| Staff G | Certified Nursing Assistant (CNA) | Named in nursing staff sufficiency findings |
| Staff B | Registered Nurse (RN) | Named in infection prevention findings |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Named in multiple findings including dignity, pain management, staffing, and trauma-informed care |
| Staff C | Certified Nursing Assistant (CNA) | Named in nursing staff sufficiency and shower delay findings |
| Staff N | Certified Nursing Assistant (CNA) | Named in trauma-informed care findings |
| Staff H | Activity Staff | Named in activity program deficiency findings |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 8, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Crystal Heights Care Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Census: 55
Deficiencies: 1
Date: Dec 7, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with care planning requirements for residents, specifically reviewing care plans for two residents.
Findings
The facility failed to develop and implement comprehensive care plans for 2 of 2 residents reviewed, including Resident #50 and Resident #54, as confirmed by record review and staff interviews.
Deficiencies (1)
Failure to develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Report Facts
Residents Affected: 2
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) | Responsible for care plans and confirmed lack of care plans for residents |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 4
Date: Dec 7, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards for Crystal Heights Care Center, including review of care plans, medication administration, personal care assistance, and psychotropic medication management.
Findings
The facility failed to develop and implement comprehensive care plans for residents, failed to safely transport insulin needles, failed to monitor personal care completion resulting in skin breakdown, and failed to re-evaluate psychotropic medications for unnecessary use. The deficiencies were noted with minimal harm or potential for actual harm affecting a few residents.
Deficiencies (4)
Failed to develop and implement a comprehensive care plan for 2 of 2 residents reviewed (Resident #50 and Resident #54).
Failed to safely transport prepared insulin needles from medication cart to residents (Resident #34, #40).
Failed to monitor completion of personal cares resulting in skin breakdown for Resident #35.
Failed to re-evaluate psychotropic and antidepressant medications for unnecessary use for 3 of 5 residents reviewed (Resident #9, #10, #28).
Report Facts
Resident census: 55
Units of Humalog insulin: 20
Units of Humalog insulin: 10
BIMS score: 12
BIMS score: 14
BIMS score: 5
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Responsible for care plans and medication review; confirmed care plans were not developed and GDR attempts were not completed. |
| Staff A | Licensed Practical Nurse (LPN) | Observed preparing and transporting insulin syringes without needle sheaths. |
| Director of Nursing | Director of Nursing (DON) | Reported expectations for needle sheath use and discussed resident care refusals and documentation issues. |
| Staff C | Certified Nursing Assistant (CNA) | Reported resident independence with cares and unawareness of skin redness. |
| Staff D | Certified Nursing Assistant (CNA) | Reported resident's partial independence and assistance needs with bathing and peri cares. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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)
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
Date: 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.
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.
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.
Deficiencies (7)
Failed to report an allegation of abuse to the State Agency within 24 hours for Resident #3's missing personal possessions.
Failed to conduct a thorough investigation of the abuse allegation for Resident #3.
Failed to utilize the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week.
Failed to remove expired medications from the medication storage room for 5 of 5 medications observed.
Failed to ensure all medication storage rooms and carts were free of expired medications.
Failed to ensure food was stored, prepared, and served under sanitary conditions; observed chips in dishes and unclean steam table.
Failed to maintain toilet seats and bed control/call light cords in safe and operating condition.
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
Date: 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.
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.
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.
Deficiencies (3)
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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