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On Medicare Special Focus status, a serious quality warning. Visit in person and ask tough questions before deciding.
based on 39 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
Medicare Special Focus status indicates a history of serious quality problems and heightened oversight. Review the latest inspection records, ask what corrective actions remain open, and visit in person before deciding.
Royal Oaks Nursing and Rehabilitation Center receives highly polarized feedback, with some families praising the rehab therapy team and administrative responsiveness, while others report severe neglect and poor care standards. Critical concerns include reports of residents being left in soiled conditions, unresponsive staff, medication errors, and a general lack of compassion from aides. Families considering this facility should be aware of the stark contrast between positive experiences during short-term rehab and reports of declining standards in long-term care.
Quality Themes
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Concerns
Rating Trends
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Distribution · 49 analyzed
This facility responds to some reviews.
Personalized based on this facility's data
Key Review Excerpts
“My gma was there for a few years. It was awful. I often found her in cold urine soaked clothing. Her room always smelled like urine. I would change her sheets that would have multiple stains of urine weekly.”
“The staff here is absolutely wonderful! Always so kind and welcoming to vendors, families, and residents.”
“My father who can be a,demanding and difficult person at times has had nothing but EXCEPTIONAL CARE. 5 STARS PLUS. I am a retired nurse of 35 years and know the demands of LTC.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
5
measures
10
measures
2
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose walking got worse
Residents vaccinated for the flu
Residents whose bladder or bowel control got worse
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
This facility has a concerning pattern with families frequently filing complaints (37 out of 80 total deficiencies), indicating persistent issues with care quality, medication management, and safety hazards. The most recurring problems involve resident care planning and treatment, medication errors and pharmacy services, and accident prevention. While the facility corrects violations when cited, the repeated nature of similar deficiencies—particularly in essential areas like medication safety and care standards—suggests ongoing operational challenges that families should carefully evaluate before placement.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Resident Rights Deficiencies
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Quality of Life and Care Deficiencies
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Emergency Preparedness Deficiencies
List the names and contact information of those in the facility.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Egress Deficiencies
Install proper backup exit lighting.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the use and maintenance of medical gas equipment.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies
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.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Federal Penalties
Fine
Oct 22, 2025
$16,907
Fine
Dec 12, 2024
$71,136
Fine
Dec 6, 2023
$34,902
Payment Denial
Dec 6, 2023
41-day denial
Source: Iowa Dept. of Inspections, Appeals & Licensing
Fed violations: 0, State violations: 0
Fed violations: 7, State violations: 1
Fed violations: 5, State violations: 0
Fed violations: 7, State violations: 1
Fed violations: 0, State violations: 0
Fed violations: 0, State violations: 0
Fed violations: 3, State violations: 1
Fed violations: 0, State violations: 0
Royal Oaks Nursing and Rehabilitation Center
for profit
Cedar View Holdings
9 facilities nationwide
Chain avg rating: 1.3/5 · Rank 6 of 7 (Lowest rating)
Owners
Amaranthine Holdings LLC
Owner · Organization
Cedar View Holdings LLC
Owner (parent company) · Organization
Cedar View Tr
Owner (parent company) · Organization
Iowa 5784 LLC
Owner (parent company) · Organization
Samara Family Holdings LLC
Owner (parent company) · Organization
Greatorex, Tina
Owner (parent company)
Schiowitz, Marc
Owner (parent company)
Sebbag, Gabriel
Owner (parent company)
Key personnel
Contact this facility directly and verify the details that matter most to your family.
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
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Google Reviews
39 reviews from families & visitors
Official Website
Visit royaloaksnursing.com
Medicare data downloads
Original nursing home datasets
EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Some summaries, interpretations, suggested questions, and pricing research are AI-generated or AI-assisted and may contain errors or omit important context. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
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