Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crystal Heights Care Center during CMS and state inspections, most recent first.
A resident with cancer, debility, failure to thrive, severe cognitive impairment, and hospice services was observed with the left arm tightly held to the chest and the left wrist fixed downward, and could not move the left wrist when prompted. The record lacked documentation of completed ROM exercises, staff said no one assigned ROM, and interviews showed the arm had become progressively stiffer and contracted while the hospice team and facility each assumed the other was managing ROM.
Meals and room trays were not served on time for multiple residents. Residents with intact cognition and diagnoses including dementia, depression, anxiety, HF, HTN, and CAD reported late lunch service, and staff observations showed the last dining room meal was served before room trays were even started. Staff could not explain the delay, and one tray was delivered uncovered while drinks were still pending.
A resident with dementia, anxiety, and depression, but intact cognition on MDS, reported that residents did not have access to their money on weekends and was still waiting for items on a shopping list. Staff said money was only available during weekday business hours, one staff member held the only key to the cash box, and an activities assistant could not shop for residents because she could not obtain the funds. The administrator stated there was no weekend plan for resident access to money and that a communication breakdown prevented shopping for multiple residents.
Failure to provide planned activities and supervision on the Memory Care unit affected residents with dementia and cognitive impairment. A resident with severe cognitive impairment wandered unsupervised and took another resident’s drink while staff were absent from the common area. Two other residents with dementia had activity plans for structured engagement and social interaction, but staff only briefly offered a coloring picture or snacks/drinks and then left, while the TV played and no staff stayed to engage the residents. Interviews confirmed activity staff spent limited time on the unit and meal times reduced activity coverage.
Failure to Conduct QA Activities for Identified Facility-Wide Concerns: The facility did not carry out QA activities to obtain feedback, use data, or analyze underlying causes for facility-wide issues affecting quality of care, quality of life, and resident safety. The QAPI policy called for a systematic, interdisciplinary, data-driven approach, but staff did not discuss resident personal funds or activities in QA. A PIP for the dementia unit noted inactivity, wandering, falls, and inconsistent participation in structured activities, yet the records lacked further evaluation of the PIP and lacked documentation of QA activities related to resident access to personal funds.
A resident with severe cognitive impairment and diabetes experienced a hypoglycemic episode and was mistakenly administered Enoxaparin instead of Glucagon by an RN, due to the pharmacy placing the wrong medication in the emergency kit compartment. The error was discovered after the resident's blood sugar remained low and EMS was called to provide further care.
Surveyors found that care plans were not consistently updated to reflect residents' current needs, such as hospice services, transfer assistance, and activity preferences. Several residents' care plans contained outdated or inaccurate information, and documentation of required care conferences was missing for multiple residents. Staff interviews and record reviews confirmed these deficiencies.
The facility did not provide a structured activity program for residents in the memory care unit, resulting in several residents with dementia and cognitive impairment lacking access to meaningful activities. Interviews with residents, family members, and staff revealed no activity calendar, no scheduled activities, and a lack of staff dedicated to activities, despite facility policy requiring individualized programming.
A resident with intact cognition and multiple diagnoses was unable to access her personal funds when requested, as the Business Office Manager only made bank trips on a set day each week, resulting in a delay. Facility policy stated that funds should be provided upon request, but this was not followed.
A resident with severe cognitive deficits and multiple medical conditions had conflicting documentation regarding code status, with some records indicating CPR and others DNR, and no clear inclusion of hospice status in the care plan. The ADON was unable to confirm if the code status had changed with the start of hospice, and no advance directives policy was available.
Staff failed to accurately complete MDS assessments for two residents, resulting in documentation that did not reflect their actual clinical status. One resident with Alzheimer's and significant lower extremity impairment was incorrectly coded as having no impairment, while another was erroneously documented as using a mechanical ventilator despite not requiring one.
A resident with severe cognitive impairment and dependence on staff for toileting was not assisted to the bathroom after expressing the need during a meal. Despite staff and policy expectations to provide toileting assistance upon request, the resident remained in the dining room without being taken to the bathroom.
A resident with severe cognitive impairment and a history of frequent pain verbally expressed discomfort multiple times during meals, but staff did not document any pain assessment, interventions, or administration of PRN acetaminophen as ordered. The care plan and facility policy required pain assessment and interventions, but these were not carried out or recorded by staff present, including an LPN and CNAs.
Two residents identified as trauma survivors, including one with PTSD, did not have their trauma histories, triggers, or specific interventions addressed in their care plans. Staff interviews revealed a lack of awareness about these residents' trauma histories, and the affected resident reported ongoing PTSD symptoms and not being included in care planning meetings. The facility did not ensure trauma-informed care or staff knowledge for these residents.
Two residents with severe cognitive impairments were not treated with dignity when staff failed to assist them to the bathroom upon request and did not acknowledge a resident's stated food temperature preference. Staff followed rigid schedules rather than responding to individual needs, and concerns voiced by residents were dismissed or ignored by CNAs and an LPN.
Multiple residents with significant care needs experienced delays in receiving assistance with bathing, toileting, and personal hygiene due to insufficient nursing staff, particularly during evening and weekend shifts. Staff and resident interviews, as well as facility records, confirmed that low staffing levels led to missed or late showers and prolonged call light response times.
Staff failed to perform hand hygiene between preparing and administering oral medications to multiple residents and did not sanitize the rubber stopper of a multi-use insulin vial before preparing an insulin injection for a resident with diabetes. These actions were not in accordance with facility policies for infection prevention and control.
Failure to Provide ROM Care
Penalty
Summary
The facility failed to ensure staff provided range of motion (ROM) exercises to maintain functional status and prevent contractures for Resident #37, who had diagnoses including cancer, age-related debility, adult failure to thrive, severely impaired cognition, and hospice services during the lookback period. The resident’s MDS assessments documented varying ROM findings over time, including later impairment in both upper and lower extremities, and on observation the resident was seen sitting at the nursing station with the left arm held tightly to the chest and the left wrist bent downward at a 90-degree angle. When asked to move the wrist, the resident could move the right wrist but could not move the left wrist. The record lacked documentation that ROM exercises were completed. A Condition Follow-Up Note documented a contracture to the resident’s left arm, with the arm held stiffly across the abdomen and chest. Staff interviews indicated the left arm had become progressively stiffer and contracted, and multiple staff stated no one had assigned them to complete ROM. The Therapy Director stated hospice would carry out ROM if the resident received hospice care, while the Hospice Director stated there was nothing on the care plan related to ROM and assumed the facility managed it. The ADON stated the facility did not have a ROM program, but knew one needed to exist.
Delayed Meal and Room Tray Service
Penalty
Summary
Meals were not served in a timely manner for 7 of 7 residents reviewed for meal service. The facility’s meal schedule listed lunch at 11:30 AM in the Assisted Dining Room and 12:00 PM in the Main Dining Room, but it did not indicate when residents in their rooms were to receive lunch. On 7/13/26, Resident #3, who had diagnoses including heart failure, non-Alzheimer’s dementia, and anxiety disorder and a BIMS score of 15, received lunch in her room at 1:24 PM. Resident #55, who had diagnoses including non-Alzheimer’s dementia, anxiety disorder, and depression and a BIMS score of 15, stated at 12:35 PM that meals arrived late. Resident #58, who had diagnoses including depression, high blood pressure, and coronary artery disease and a BIMS score of 15, stated at 2:40 PM that lunch was received around 1:30 PM, as usual. Additional observations showed delayed room tray delivery throughout the meal period. Resident #64 stated residents should receive food by 12:30 PM and that 12:30 PM was the latest she wanted to eat; she also stated meals usually arrived late and that she had reported this without seeing changes. Resident #68 stated meals arrived late sometimes and expressed frustration about available options. At 1:00 PM, the last meal in the main dining room was served, and room trays were not brought out until 1:11 PM. Resident #38 stated at 1:20 PM that she wished staff would bring food because she was hungry and wanted tea. Staff C stated one staff member usually passed out room trays while another cleaned the dining room, but did not know why meal delivery took so long that day. Staff H later carried an uncovered tray to Resident #28’s room at 1:35 PM and said drinks still needed to be obtained, but did not return with them.
Failure to Provide Timely Access to Resident Funds
Penalty
Summary
The facility failed to ensure residents had timely access to their personal funds for shopping needs, affecting 1 of 1 resident reviewed for personal funds and 9 of 9 additional residents on the Week 1 Resident Shopping List. Resident #55 had diagnoses of non-Alzheimer's dementia, anxiety disorder, and depression, and the MDS documented a BIMS score of 15, indicating intact cognition. During interview, Resident #55 stated residents did not have access to their money on weekends and that she was still waiting for items on a shopping list. The Accounts Receivable Policy and Procedure dated 7/7/26 instructed the facility to ensure residents had appropriate access to their funds. Staff A, the Administrative Assistant, stated residents could access their money only Monday through Friday from 8:00 AM to 4:30 PM and that she held the only key to the cash box. Staff B, the Activities Assistant, stated she was unable to go shopping for any residents on the Week 1 Resident Shopping List because she could not obtain money from Staff A. Staff C, the Administrator, stated the facility did not have a plan for residents to get money on weekends and later stated a breakdown in communication prevented staff from shopping for residents the previous week.
Failure to Provide Planned Activities and Supervision on Memory Care Unit
Penalty
Summary
The facility failed to ensure staff provided planned activities and supervision for 3 residents on the Memory Care Unit. Resident #17 had a BIMS score of 0, wandered 4 to 6 days in the 7-day look-back period, and had diagnoses including vascular dementia with agitation, anxiety disorder, depression, seizure disorder, and epilepsy. The care plan identified that the resident enjoyed walking around the unit, visiting with others, helping staff with tasks, and talking with family, and directed staff to give step-by-step instructions, keep a consistent routine, and use consistent caregivers when possible. On 7/15/26, the Memory Care Unit white board listed activities including ring toss, a movie, and coffee time, but Resident #17 was observed wandering in the common area while no staff remained in the area. The resident took chocolate milk from another resident’s walker seat and drank it while the other resident tried to stop him, and staff were not present to observe the interaction. Staff later walked through the area and left again, with no staff staying in the common area to supervise residents during this time. Resident #20 had a BIMS score of 9 and a diagnosis of Alzheimer’s dementia. The care plan directed staff to engage the resident in simple, structured activities such as folders club, live entertainment, and watching TV/movies, and to provide an activity calendar and notify the resident of changes. Resident #19 had a BIMS score of 4 and a diagnosis of Alzheimer’s dementia, with care plan interventions to invite the resident to scheduled activities his wife attended and to support social interaction and leisure time. On the dates observed, the unit activity board listed scheduled activities, but staff only briefly brought a coloring picture to one resident, asked another resident what he wanted to drink or eat, and then left the area; residents sat in the TV/common room eating snacks and drinking while the TV played, with no staff staying to engage them. Staff interviews confirmed activity staff spent limited time on the Memory Care Unit and that meal times affected activity coverage, and the ADON agreed the facility could do more and confirmed activity staff did not spend more than 45 minutes a day on the unit.
Failure to Conduct QA Activities for Identified Facility-Wide Concerns
Penalty
Summary
The facility failed to carry out Quality Assurance (QA) activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The Quality Assurance and Performance Improvement (QAPI) policy dated April 2025 directed staff to continually assess facility performance using a systematic, interdisciplinary, comprehensive, and data-driven approach to maintain and improve safety and quality. The CMS Form 2567 dated 6/26/25 identified concerns related to residents having access to personal funds and activity provision. During record review and interviews from 7/13/26 to 7/16/26, the same concerns were identified. On 7/16/26, the Administrator stated staff did not discuss personal funds or activities in QA. A Performance Improvement Plan dated 5/26/26, sent by the Administrator on 7/17/26, identified increasing activities in the dementia unit and documented unit observations of inactivity, increased wandering behaviors, increased falls, and inconsistent participation in structured activities. The facility records lacked further evaluation of the activity PIP and lacked documentation of QA activities related to resident access to personal funds.
Medication Administration Error Due to Incorrect Emergency Kit Stocking
Penalty
Summary
A medication administration error occurred when a registered nurse administered the wrong medication to a resident with severe cognitive impairment and multiple complex medical conditions, including diabetes mellitus with a risk for hypoglycemia. The resident experienced critically low blood sugar levels, and the nurse, responding to the hypoglycemic episode, retrieved what he believed to be Glucagon from the emergency kit. However, the syringes in the compartment labeled Glucagon actually contained Enoxaparin, an anticoagulant, due to a pharmacy error in stocking the kit. The nurse administered two doses of Enoxaparin instead of Glucagon before realizing the mistake after reviewing the packaging post-administration. The resident's blood sugar remained dangerously low despite the interventions, prompting the nurse to call emergency medical services. Upon arrival, EMTs administered intravenous dextrose, and the nurse discovered the medication error. The incident was further confirmed by the Director of Nursing, who stated that the pharmacy had incorrectly placed Enoxaparin syringes in the Glucagon compartment and vice versa. The resident was subsequently transferred to the emergency room for further observation due to persistent altered mental status.
Care Plan Deficiencies and Lack of Documentation
Penalty
Summary
The facility failed to ensure that care plans were accurately developed, updated, and individualized for several residents, as required. For multiple residents, care plans did not reflect current clinical needs or services, such as hospice care, transfer assistance requirements, and behavioral interventions for conditions like PTSD. In one instance, a resident receiving hospice care was not identified as such in the care plan, and another resident's care plan did not match the documented need for assistance with transfers, despite staff providing substantial help during observed care. Additionally, care plans for residents with cognitive impairments lacked updates on their interests, preferences, and activity options, and in some cases, contained inaccurate cognitive assessment scores. The facility also failed to document care conferences as required, with several residents not having records of care conferences during the survey year. One resident reported not being invited to care conferences, and the Assistant Director of Nursing confirmed the absence of documentation due to personnel changes. Facility policies required that activity interests be identified in the care plan and reviewed quarterly, and that care conferences occur quarterly, but these requirements were not consistently met. These deficiencies were identified through observation, clinical record review, policy review, and staff interviews.
Failure to Provide Individualized Activity Program in Memory Care Unit
Penalty
Summary
The facility failed to provide a comprehensive activity program tailored to meet the interests and support the physical, mental, and psychosocial well-being of residents in the Chronic, Confusion, and Dementia Illness (CCDI) unit. Multiple residents with diagnoses of non-Alzheimer's dementia, Alzheimer's disease, and vascular dementia, and with varying levels of cognitive impairment, were observed and reported to have no access to meaningful activities. Interviews with residents, their representatives, and staff revealed that there were no visible activity calendars, no scheduled or posted activities, and that residents were often unaware of any available activities, including those outside the unit. Some residents expressed interest in activities such as church services or puzzles but were not informed of these opportunities. Family members and representatives also voiced concerns about the lack of activities and engagement for their loved ones. Staff interviews confirmed that the CCDI unit had previously had a dedicated activity staff member, but this position had not been replaced after the staff member left. The current arrangement expected CNAs to provide activities as time allowed, but staff acknowledged that CNAs often did not have time to do so. The Activity Coordinator role was being filled by the Provisional Administrator, who also served as the Business Office Manager, and there was no evidence of an updated activity calendar or documentation of resident participation. Facility policy required individualized activity programming and regular assessment, but these processes were not being followed, resulting in residents not receiving activities appropriate to their needs and interests.
Resident Denied Timely Access to Personal Funds
Penalty
Summary
The facility failed to ensure that a resident with intact cognition and diagnoses including diabetes, non-Alzheimer's dementia, and anxiety disorder had ready access to her personal funds. The resident reported requesting money from the Business Office Manager (BOM) on a Monday, but was told that the BOM would not go to the bank until Thursday, resulting in a delay in accessing her funds. The BOM confirmed that she typically only went to the bank on Thursdays and could not fulfill the resident's request earlier in the week. The Assistant Director of Nursing (ADON) stated her understanding that residents should have access to their money, and the facility's policy indicated that money would be provided upon request, in accordance with state laws and facility policies.
Inconsistent Documentation of Code Status for Resident on Hospice
Penalty
Summary
The facility failed to ensure consistent documentation of code status for a resident reviewed for advance directives. The resident had a Code Status form indicating CPR, but the care plan did not include code status or mention hospice services. The resident's quarterly MDS assessment showed enrollment in hospice and severe cognitive deficits, while the Pocket Care Plan also directed CPR. However, the resident's chart binder was labeled as Do Not Resuscitate (DNR), and the electronic census confirmed the start of hospice services. During an interview, the ADON was unsure if the code status had changed with the initiation of hospice and acknowledged discrepancies in the documentation. Additionally, the facility did not have a policy on advance directives available.
Inaccurate Resident Assessments Documented in MDS
Penalty
Summary
Facility staff failed to accurately complete assessments for two residents, resulting in Minimum Data Set (MDS) documentation that did not reflect the residents' true clinical status. For one resident with Alzheimer's disease, the MDS assessments indicated no impairment to the upper or lower extremities, despite multiple staff interviews and direct observation confirming the resident had significant bilateral lower extremity impairment, was dependent on staff for transfers, and required a Hoyer lift. Staff also reported the resident had limited range of motion in the lower extremities and had been unable to stand for an extended period, contradicting the MDS coding. In another case, the MDS for a resident with heart disease, diabetes, and lung disease was coded to indicate use of an invasive mechanical ventilator or respirator within the assessment period. However, observation and staff interviews confirmed the resident was not on a ventilator, and the room was not set up for such equipment. The Assistant Director of Nursing confirmed the MDS was coded in error and that the resident had not required ventilator support while at the facility.
Failure to Provide Timely Toileting Assistance to Dependent Resident
Penalty
Summary
A deficiency occurred when staff failed to provide timely toileting assistance to a resident with severe cognitive impairment and a diagnosis of Alzheimer's disease, anxiety disorder, and weakness. The resident was assessed as requiring substantial to maximal assistance for toilet transfers and was dependent on staff for toileting hygiene. The care plan specified that two staff members were needed for toileting. During an observed meal, the resident consumed a significant amount of fluids and verbally expressed the need to use the bathroom. Despite this, one CNA deferred action after another CNA questioned the resident's request, instructing that the resident should only be taken to the bathroom if she repeated her request. The resident was not assisted to the bathroom and remained in the dining room for an extended period. Interviews with staff, including a CNA, an LPN, and the ADON, confirmed that the expectation was to assist the resident to the bathroom upon request. The facility's policy directed staff to toilet residents before and after meals and as needed throughout the day. The failure to respond to the resident's voiced need for toileting assistance was inconsistent with both the resident's care plan and facility policy.
Failure to Provide Appropriate Pain Management
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, anxiety disorder, and weakness, and who was assessed as severely cognitively impaired, was identified as requiring scheduled pain management. The resident's care plan directed staff to attempt three non-pharmacological interventions before administering as-needed (PRN) pain medication, to administer medications as ordered, and to evaluate the effectiveness of pain interventions. Despite these directives, the resident verbally expressed pain multiple times during meals, in the presence of staff including a Licensed Practical Nurse and Certified Nursing Assistants. The clinical record for the day in question did not document any pain assessment, interventions, or administration of pain medication, even though an order for PRN acetaminophen was in place. Staff interviews confirmed that the expectation was for aides to notify a nurse if a resident reported pain, and that pain relief options such as Tylenol or muscle rubs could be provided. The facility's pain assessment policy required thorough assessment and interventions to alleviate pain. However, there was no documentation that staff assessed the resident's pain or implemented any interventions on the day the resident reported discomfort, indicating a failure to follow the care plan and facility policy for pain management.
Failure to Provide Trauma-Informed Care for Trauma Survivors
Penalty
Summary
The facility failed to provide trauma-informed care for two residents identified as trauma survivors, including one resident with a diagnosis of PTSD. Clinical record review showed that the care plan for this resident did not address their trauma history, PTSD, or specific triggers and interventions, despite documentation of related diagnoses and symptoms. The care plan only included general interventions for depression and anxiety, omitting trauma-specific needs. Staff interviews revealed a lack of awareness among nursing, activity, and social work staff regarding the resident's trauma history, with several staff members unaware of the PTSD diagnosis or the need for trauma-informed interventions. The resident reported not being invited to care plan meetings and described ongoing PTSD symptoms, including nightmares and withdrawal when triggered. The Assistant Director of Nursing acknowledged not realizing the resident was a trauma survivor until recently, and the acting social worker was also unaware of the resident's trauma history, despite being responsible for assessments. The Advanced Registered Nurse Practitioner confirmed that PTSD was the main mental health issue for the resident. These findings indicate that the facility did not ensure trauma-informed care planning or staff awareness for residents with a history of trauma.
Failure to Honor Resident Dignity in Toileting and Food Preferences
Penalty
Summary
The facility failed to honor the dignity and preferences of two residents by not responding appropriately to their expressed needs for toileting assistance and food temperature preferences. One resident, with diagnoses including severe intellectual disability and a BIMS score indicating severely impaired cognition, was observed to request assistance to the bathroom but was told by a CNA that it was not time yet and was not assisted. Staff interviews confirmed that the resident was on a two-hour toileting schedule, and there were instances when staff did not assist the resident outside of this schedule, despite her requests. The resident's care plan directed staff to anticipate her needs and respond to her calls for assistance with incontinence episodes. Another resident, diagnosed with Alzheimer's disease and severe cognitive impairment, required substantial assistance for toileting. During a meal, the resident expressed the need to use the bathroom, but staff did not immediately assist her and continued feeding her instead. Additionally, this resident communicated that her oatmeal was too hot, but the LPN dismissed her concern and attempted to feed her another bite. The facility did not have a policy related to dignity, as confirmed by the Assistant Director of Nursing.
Insufficient Nursing Staff Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by multiple reports from residents and staff, as well as documentation review. One resident with intact cognition and multiple diagnoses, including heart failure and PTSD, required partial to moderate assistance with bathing and personal hygiene. This resident reported not consistently receiving scheduled showers twice per week, with some showers offered as late as 10:00 PM, leading to refusals due to the late hour. Bathing records confirmed refusals due to lateness, and a CNA corroborated that staffing shortages, especially on certain shifts, resulted in delayed care. Observations during interviews noted the resident's unkempt appearance, further supporting the deficiency. Additional residents with extensive care needs, including assistance with toileting and transfers, reported excessive wait times for staff response to call lights, sometimes up to an hour or more, particularly after meals and during evening hours. Staff interviews confirmed that weekend staffing was especially inadequate, with as few as 2-3 CNAs available, making it difficult to complete resident care tasks in a timely manner. Facility records and staffing data indicated a pattern of low staffing, particularly on weekends, and the Assistant Director of Nursing acknowledged ongoing staffing challenges over the past five years.
Failure to Follow Infection Control Protocols During Medication Administration
Penalty
Summary
Staff failed to follow infection prevention and control protocols during medication administration. Specifically, a registered nurse did not perform hand hygiene, either by hand washing or using an alcohol-based hand rub, before preparing and between administering oral medications to multiple residents. The nurse was observed handling medications, feeding residents, touching residents and their wheelchairs, and returning to the medication cart without sanitizing hands between residents. Facility policy required thorough hand washing before and after providing resident care, but this was not followed during two observed medication administration times. Additionally, another registered nurse did not sanitize the rubber stopper of a multiple-use insulin vial before preparing an insulin injection for a resident with diabetes mellitus. The nurse removed the insulin syringe from its packaging and inserted it directly into the vial without using an alcohol wipe, contrary to facility policy, which instructed staff to swab the rubber stopper with an alcohol sponge prior to inserting the needle. The resident's care plan for diabetes mellitus also lacked focus areas, goals, or interventions related to the diagnosis.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oskaloosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oskaloosa Care Center | 0.4 mi | ★★★★★ | 8 | 0 |
| Northern Mahaska Specialty Care | 1.6 mi | ★★★★★ | 9 | 0 |
| The Cottages | 15.9 mi | ★★★★★ | 4 | 0 |
| Oakwood Specialty Care | 20.8 mi | ★★★★★ | 0 | 0 |
| Montezuma Specialty Care | 20.9 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.