Royal Oaks Nursing and Rehabilitation Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 40 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (1/5 stars)
- Low staffing rating (2/5 stars)
- Above-median deficiencies (15 vs median 5)
- High staff turnover (62%)
- High RN turnover (88%)
Bottom 25% in IA · Below recommended RN staffing · Worst in GABRIEL SEBBAG & THE SAMARA FAMILY chain · $122,691 in fines
What this means for your family
While the facility's rehabilitation department receives consistent praise, there is a recurring pattern of serious neglect in long-term care, specifically regarding hygiene and call-light response times. If you choose this facility, we strongly recommend frequent, unannounced visits during evening and weekend hours to ensure your loved one's needs are being met when management is off-site.
Google Reviews
Google Reviews
40 reviews on Google“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
Tap a score for detailsStrengths
- Effective rehabilitation therapy team
- Responsive administrative enrollment process
- Kind and attentive individual staff members
- Clean, well-maintained courtyard
Concerns
- Neglect of hygiene and basic resident care (soiled briefs, lack of water) (mentioned by 4 reviewers)
- Unresponsive or slow call light response times (mentioned by 3 reviewers)
- Staff turnover and inconsistent care quality (mentioned by 3 reviewers)
- Medication management and reporting errors (mentioned by 2 reviewers)
- Rude or dismissive behavior from nursing assistants (mentioned by 4 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 49 analyzed
How They Respond to Reviews
This facility responds to some reviews.
Questions for Your Tour
- 1Given the recent focus on improving staff consistency, what specific steps is the facility taking to ensure residents receive reliable, daily hygiene and hydration support?
- 2I noticed the courtyard is a beautiful space; how do you encourage residents to spend time there, and what other daily activities are available to keep them engaged?
- 3Could you walk me through your current medication management process and how you ensure accuracy and timely reporting for family members?
- 4When a resident uses their call light, what is your standard protocol for response times, and how do you monitor those interactions to ensure staff remain attentive and kind?
- 5I see that you have been active in responding to feedback online; how do you incorporate that family input into your daily care routines and staff training?
- 6What is your process for managing medical emergencies, and how do you communicate changes in a resident's health status to their family members?
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.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
5
measures
11
measures
1
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents vaccinated for the flu
Residents on antipsychotic medication
Residents whose bladder or bowel control got worse
Residents on anti-anxiety or sleep medication
Residents whose walking got worse
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
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
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.
Feb 11, 2026Complaint7
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
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 appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Oct 22, 2025Complaint3
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.
May 20, 2025Complaint6
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.
May 20, 2025Routine18
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.
Dec 13, 2024Complaint12
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.
Oct 15, 2024Complaint3
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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
Payment Denial
May 17, 2023
55-day denial
State Inspection History
State Inspections
Source: Iowa Dept. of Inspections, Appeals & Licensing
Apr 9, 2026ComplaintClean
Fed violations: 5, State violations: 0
Feb 11, 2026ComplaintClean
Fed violations: 7, State violations: 1
Dec 11, 2025ComplaintClean
Fed violations: 0, State violations: 0
Nov 7, 2025ComplaintClean
Fed violations: 0, State violations: 0
Oct 22, 2025ComplaintClean
Fed violations: 3, State violations: 1
Jul 17, 2025InspectionClean
Fed violations: 0, State violations: 0
Jul 17, 2025ComplaintClean
Fed violations: 0, State violations: 0
May 20, 2025InspectionClean
Fed violations: 13, State violations: 1
Ownership & Operations
Who Operates This Facility
Royal Oaks Nursing and Rehabilitation Center
for profit
Chain Affiliation
Gabriel Sebbag & the Samara Family
7 facilities nationwide
Chain avg rating: 1.3/5 · Rank 6 of 7 (Worst)
Ownership & Management
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
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
40 reviews from families & visitors
Official Website
Visit royaloaksnursing.com
Medicare data downloads
Original nursing home datasets
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