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.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
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)
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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
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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.