Royal Oaks Nursing and Rehabilitation Center
4614 Nw 84th Street · Urbandale, IA · 50322 · 5152706838
115 certified beds For profit - Corporation Chain: Cedar View Holdings
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $88,043 in fines in the last 24 months.
- 5 citations involved actual harm to residents.
Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
3 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$88,043 in federal fines in the last 24 months
2 fines — CMS fines are reserved for verified, serious non-compliance.
RN staffing in the bottom 10% nationally
0.26 registered-nurse hours per resident per day, vs a 0.58 national median and 0.75 benchmark.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.34 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.26 | 0.55–0.75 |
| Weekend hours / resident-day | 3.00 | ≈ weekday level |
| Nursing turnover / year | 55% | median 45% |
| Fines (3-yr window) | 3 · $122,945 |
Inspection citations (71 in the current record)
-
Potential for harm · D April 9, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has no plan of correction · Quality of Life and Care
-
Potential for harm · D April 9, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has no plan of correction · Quality of Life and Care
-
Potential for harm · D April 9, 2026 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has no plan of correction · Quality of Life and Care
-
Potential for harm · D April 9, 2026 · found via complaint
Ensure that residents are free from significant medication errors.
Deficient, Provider has no plan of correction · Pharmacy Service
-
Potential for harm · D April 9, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Deficient, Provider has no plan of correction · Infection Control
-
Actual harm · G February 11, 2026 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has plan of correction · Quality of Life and Care
-
Potential for harm · D February 11, 2026 · found via complaint
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected February 23, 2026 · Resident Rights
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Potential for harm · E February 11, 2026 · found via complaint
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected February 23, 2026 · Resident Rights
-
Potential for harm · D February 11, 2026 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected February 23, 2026 · Resident Assessment and Care Planning
-
Potential for harm · D February 11, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has plan of correction · Quality of Life and Care
-
Potential for harm · D February 11, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected February 23, 2026 · Quality of Life and Care
-
Potential for harm · E February 11, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Deficient, Provider has plan of correction · Infection Control
-
Immediate jeopardy · K October 22, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected October 9, 2025 · Nursing and Physician Services
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Potential for harm · D October 22, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 7, 2025 · Quality of Life and Care
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Potential for harm · D October 22, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected November 7, 2025 · Resident Assessment and Care Planning
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Actual harm · G May 20, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 13, 2025 · Quality of Life and Care
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Actual harm · G May 20, 2025 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected June 13, 2025 · Pharmacy Service
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Potential for harm · D May 20, 2025
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected June 13, 2025 · Resident Assessment and Care Planning
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Potential for harm · D May 20, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected June 13, 2025 · Resident Assessment and Care Planning
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Potential for harm · D May 20, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected June 13, 2025 · Quality of Life and Care
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Potential for harm · E May 20, 2025
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected June 13, 2025 · Nutrition and Dietary
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Potential for harm · E May 20, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected June 13, 2025 · Resident Assessment and Care Planning
-
Potential for harm · E May 20, 2025
Provide and implement an infection prevention and control program.
Corrected June 13, 2025 · Infection Control
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Potential for harm · D May 20, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected June 13, 2025 · Resident Rights
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Potential for harm · D May 20, 2025 · found via complaint
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected June 13, 2025 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 22, 2025 | Fine | $16,907 |
| December 12, 2024 | Fine | $71,136 |
| December 6, 2023 | Fine | $34,902 |
| December 6, 2023 | Payment Denial | 41 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 165580 · certified since July 9, 2007. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.