Crystal Heights Care Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

Therapy staffing: this home’s payroll records show 0.49 therapist hours per resident per day in 2026Q1 — more than 80% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 72 beds and averages 66.5 residents a day — about 92% occupied, or roughly 6 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.40 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.25 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.59 hrs/resident/day on weekends vs 3.26 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.45 to 0.29 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 64% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.

• Potential for harm · D2025-12-08 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Clinical record review and staff interview, the facility failed to follow medication administration protocol resulting in the wrong medication being administered. (Resident#1). The facility reported census was 70.Findings include: According to a Minimum Data Set (MDS) with a reference date of November 7, 2025, Resident #1 had a Brief Mental Status (BIMS) score of 0 of 15 indicating a severely impaired cognitive status. Resident #1 required moderate to maximal assistance with transfers, mobility, dressing, toilet use and personal hygiene needs. Resident #1's diagnosis included Non-Alzheimer's dementia, cancer, renal insufficiency, arthritis, diabetes mellitus, gastroesophageal reflux disease and malnutrition.According to Resident #1's Care Plan, Resident #1 was diagnosed with diabetes mellitus with risk for hypoglycemia (low blood sugar) and interventions which included fasting serum blood sugars as ordered, monitor for hypoglycemia and provide diabetic medications as ordered.Review of Resident #1's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-26 · tag F0657 — failed to keep the care plan current — pattern
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure the Care Plan identified Hospice services, correct transfer status, activities, and behavioral interventions for Post-Traumatic Stress Disorder (PTSD), and lacked documentation of care conferences conducted for 7 of 19 residents reviewed for Care Plans (Residents #15, #33, #34, #37, #44, #56 #61). The facility reported a census of 62 residents. Findings include: 1. The Quarterly Minimum Data Set(MDS) assessment tool, dated 4/23/25, listed diagnoses for Resident #33 which included diabetes, non-Alzheimer's dementia, and anxiety disorder. The MDS listed the resident's Brief interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. On 6/24/25 at 10:27 a.m., Resident #33 stated the facility did not invite her to care conferences. A Care Conference Summary, dated 4/23/25, stated the resident had a care conference in her room with a staff nurse and the Assistant Director of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-06-26 · tag F0679 — failed to provide activities — pattern
  Provide activities to meet all resident's needs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, representative, staff interviews, record review, and facility policy review the facility failed to provide the residents in the Chronic, Confusion, and Dementia Illness (CCDI) unit a activity program built to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Findings include: 1. A Quarterly Minimum Data Set, dated [DATE] for Resident #15 documented diagnosis, non-Alzheimer's dementia and coded wore a wander/elopement alarm. The Brief Interview for Mental Status (BIMS) assessment coded 00 to reflect resident, was not able to take assessment. In an interview on 6/23/25 at 4:34 PM with representative of resident #15 relayed there is nothing at all related to activities and is concerning, had not seen or heard of any activities, never seen anything posted, relayed books are provided but, did not think reading was an option anymore due to dementia progression and Resident #15 no longer wearing her glasses. 2. The MDS assessment dated [DATE] for…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-26 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  3. On 6/25/25 at 8:05 AM, observation of Resident #14 revealed the resident was sitting in the dining room with Staff A, LPN (Licensed Practical Nurse), next to her. Staff A fed the resident a bite of oatmeal. Resident #14 said, That's too hot. Staff A responded that it wasn't too hot and tried to give the resident another bite. Resident #14 stated, If you burned your mouth you would think it was too hot too. Resident #14 refused to eat any more of the oatmeal. Based on observation, clinical record review, and staff interview, the facility failed to treat 2 of 5 residents reviewed for dignity with respect by failing to assist a resident to the bathroom when the need was voiced (Residents #14 and #44) and by failing to acknowledge a resident's food temperature preferences (Resident #14). The facility reported a census of 62 residents. Findings: 1. The Annual Minimum Data Set(MDS) assessment tool, dated 5/28/25, listed diagnoses for Resident #44 which included anxiety disorder, severe intellectual disability, and depression. The MDS stated the resident required partial to moderate…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-26 · tag F0567 — failed to protect residents' money held by the home — isolated
  Honor the resident's right to manage his or her financial affairs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on clinical record review, policy review, and staff and resident interviews, the facility failed to ensure residents had ready access to their personal funds for 1 of 1 residents reviewed for personal funds(Resident #33). The facility reported a census of 62 residents. Findings include: The Annual Minimum Data Set (MDS) assessment tool, dated 4/23/25, listed diagnoses for Resident #33 which included diabetes, non-Alzheimer's dementia, and anxiety disorder. The MDS listed the resident's Brief interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. On 6/24/25 at 10:27 a.m., Resident #33 stated she requested money on Monday(6/23/25) from the Business Office Manager (BOM) but she told her she would not go to the bank until Thursday(6/26/25). On 6/25/25 at 1:10 p.m., the BOM stated she handled resident funds in the facility. She stated she normally went to the bank on Thursday. She stated on Monday, Resident #33 requested money and she told her she couldn't get to the bank until Thursday. On 6/26/25 at 12:19 p.m., the Assistant Director of Nursing…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-26 · tag F0578 — failed to honor advance directives / code status — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Code Status Form, observation, record review and interview the facility failed to ensure consistent documentation of code status for 1 of 24 resident reviewed for advanced directives (Resident #15). The facility reported a census of 72 residents. Findings include: The Code Status form signed by Resident #15 on [DATE] directed CPR referring to cardiopulmonary resuscitation. The Care Plan initiated [DATE] for Resident #15 lacked code status and did not indicate hospice services. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 on hospice services. Medical diagnoses included heart disease, renal disease, diabetes and dementia. The Brief Interview for Mental Status (BIMS) exam scored 3 out of 15 indicating severe cognitive deficits. The Pocket Care Plan (condensed Care Plan directing resident cares) undated directed CPR. Observation of the Binder (chart) for Resident #15 directed Do Not Resuscitative (DNR) was wrote on the spine of the binder. The Electronic Census record…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-26 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation and staff interviews, the facility failed to ensure staff completed the assessment of residents to accurately reflect their status for 2 of 19 sampled residents (Resident #18 and #12). The facility reported a census of 62 residents. Findings included: 1. The Quarterly Minimum Data Set (MDS) assessments for Resident #18, dated 3/5/25 and 6/4/25, identified a diagnosis of Alzheimer's and an admission date of 12/7/22. The assessment included documentation that the resident was dependent on staff for toileting, bathing, lower body dressing, transfers and substantial or maximum assistance for personal hygiene and rolling in bed from one side to another. The resident used a wheelchair for mobility and did not walk or stand. Her Brief Interview for Mental Status (BIMS) was documented as severely impaired with no assessed score. The same MDS assessment documented the resident did not have a impairment to upper or lower extremities. On 6/25/25 at 8:18 AM, during an interview,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-26 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
  Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, clinical record review, policy review, and staff interview, the facility failed to assist 1 of 2 residents reviewed for toileting assistance to the bathroom when the need was voiced(Resident #14). The facility reported a census of 62 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 5/14/25, listed diagnoses for Resident #14 which included Alzheimer's disease, anxiety disorder, and weakness. The MDS stated the resident required substantial to maximal assistance for toilet transfers and was dependent on staff for toileting hygiene. The MDS listed her cognition as severely impaired. A 9/13/23 Care Plan entry stated the resident required the assistance of two staff for toileting needs. On 6/24/25 at 11:36 a.m., Resident #14 sat at a dining room table and drank approximately 240 milliliters(ml) of chocolate milk. Staff then provided her another cup of milk, and she drank a portion of this as well. At 11:55 a.m., Staff I Certified Nursing Assistant(CNA) fed the resident and the resident stated she had to go to the bathroom.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-26 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure 1 of 1 resident reviewed for pain received treatment and care related to pain management(Resident #14). The facility reported a census of 62 residents. Findings include: The Quarterly Minimum Data Set(MDS) assessment tool, dated 5/14/25, listed diagnoses for Resident #14 which included Alzheimer's disease, anxiety disorder, and weakness. The MDS stated the resident was on scheduled pain medication and had no indicators of pain such as vocal complains or non-verbal sounds. The MDS listed her cognition as severely impaired. On 6/24/25 at 8:11 a.m., Resident #14 stated I hurt multiple times throughout out breakfast. Multiple staff were present in the dining room including Staff A Licensed Practical Nurse(LPN). On 6/24/25 at 11:55 a.m., Staff I Certified Nursing Assistant(CNA) fed the resident and Staff J CNA sat with another resident. The resident stated she hurt. Care Plan entries, dated 2/10/20, stated the resident reported frequent pain and discomfort to her right hip and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-06-26 · tag F0699 — isolated
  Provide care or services that was trauma informed and/or culturally competent.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident/family interview and staff interview, the facility failed to ensure residents who were trauma survivors received trauma-informed care to eliminate or mitigate triggers that might have caused re-traumatization of the resident for 2 of 2 sampled residents (Resident #1 and #34) identified by either record review or interview as being a trauma survivor. The facility reported a census of 62 residents. Findings included: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #1, dated 5/7/25, revealed the resident was admitted [DATE], scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition, had diagnoses of non traumatic brain dysfunction, heart failure, bipolar disorder, asthma and Post Traumatic Stress Disorder (PTSD). Review of the current Care Plan for Resident #1, last revised on 2/20/25, revealed the resident took anti-anxiety and antidepressant medications and was care planned for potential in alterations in…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction

Fines & penalties

$10,489 in federal fines across 1 penalty.

• $10,489 — penalty dated 2023-12-11

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 16 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 80% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $351K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IA