4614 Nw 84th Street, Urbandale, IA 50322 · Polk County · (515) 270-6838
115 certified beds, about 87 residents a day · For profit - Corporation · Medicare and Medicaid since 2007
CMS Care Compare ratings, data as of September 1, 2026 · CCN 165580 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 20, 2025, inspectors cited 12 health deficiencies (the Iowa average is 6.5, the national average 9.2).
Of 78 health citations since April 2023, 8 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 4 fines totaling $434,146 in the last three years; the largest was $311,880, and the latest is dated February 11, 2026.
Nurses and nurse aides worked 3.63 hours per resident per day, against 3.82 across Iowa and 3.86 nationally. Registered nurses accounted for 0.48 of those hours.
66.7% of nursing staff left within the year CMS measured (Iowa average 44.0%).
CMS links it to Cedar View Holdings, an affiliated group of 9 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 78 health citations on file.
Inspectors wroteBased on clinical record review, hospital record review, staff, medical provider and vendor interviews, and guidance from the 2025 Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to take steps necessary to avoid the development and worsening of a pressure ulcer for one of four (Resident #8) residents reviewed. This resulted in harm to Resident #8 when her wound continued to worsen and she was sent to the hospital for wound management on [DATE]. Upon admission to the hospital, Resident #8 was diagnosed with a sacral decubitus ulceration extending to the bone. She was additionally diagnosed with an MRSA infection (Methicillin-Resistant Staphylococcus aureus, an antibiotic-resistant infection. It causes dangerous infections when it enters the body and doesn't respond to standard medications) of the wound on [DATE]. [...]
Inspectors wroteBased on review of the Centers for Medicare & Medicaid Services (CMS) 2567's, staff interview and policy review the facility failed to have an effective QAPI (Quality Assurance Performance Improvement) process to address previously identified quality deficiencies to assist in the provision of quality care for residents and attain substantial compliance with Federal regulations and State rules. The facility had repeat deficiencies identified on the facility's recertification revisit and complaints survey. The facility identified a census of 81 residents.
Inspectors wroteBased on record review, facility investigation summary report, resident and staff interview and policy review the facility staff failed to provide care for a resident in an environment that maintained or enhanced dignity for one of six residents sampled that required assistance (Residents #1). The facility reported a census of 81 residents.
Inspectors wroteBased on observation, clinical record review, hospital record review, staff interviews, and facility policy review, the facility failed to provide adequate nursing supervision for two out of five (Resident #3 and Resident #15) residents reviewed for nursing supervision by failing to provide one person assistance to Resident #3, resulting in the resident eloping from the building. The facility additionally failed to provide staff accompaniment to an off site physician's office visit for a cognitively impaired resident (Resident #15). The facility reported a census of 81 residents.
Inspectors wroteBased on observation, staff interview, resident interview, and facility policy review, the facility failed to provide incontinence care within the time frames established in the comprehensive care plan and failed to maintain infection control standards during the provision of incontinence care for one of three (Res #18) residents reviewed. The facility reported a census of 81 residents.
Inspectors wroteBased on record review, resident and staff interview and policy review the facility failed to provide medication as ordered by the physician after the resident admitted to the facility for one of four residents reviewed for medications (Resident #2). The facility staff also failed to prepare and administer medications to one resident at a time for two of five residents observed for medication pass (Resident #13 and #14). The facility reported a census of 81 residents.
Inspectors wroteBased on the record review, observations, staff interviews and policy review the facility failed to ensure staff utilize Enhanced Barrier Precautions (EBP) and infection control practices to prevent the potential spread of infection for 1 of 3 nursing units reviewed (100 Hall). Staff reached into their uniform pocket to obtain hand sanitizer and then placed the hand sanitizer back into their uniform pocket during the course of a treatment and dressing change for 1 of 3 residents observed for treatments (Resident # 8). The facility additionally failed to properly sanitize a full body mechanical lift after resident usage and properly sanitize a mattress which was pooled with urine. The facility reported a census of 81 residents.
Inspectors wroteBased on observation, clinical record review, staff, resident, and family member interviews, the facility failed to provide necessary assistance with eating and failed to implement ordered nutritional interventions to address significant weight loss for 2 of 3 sampled residents (Resident #24 and Resident #28). Specifically, staff failed to assist residents during meals, leaving them with untouched food for extended periods, and failed to provide ordered supplements even as the residents experienced significant weight declines. The facility reported a census of 83 residents.
Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to provide proper wound care for two of two residents reviewed with pressure ulcers and failed to document a total of 9 treatments for 3 different pressure ulcers for Resident #21 and failed to document a total of 7 treatments for 3 different wounds as being completed and failed to utilize proper infection control techniques while providing wound care to Resident #22. The facility reported a census of 83 residents.
Inspectors wroteBased on observation, clinical record review, facility policy review, and staff and resident interviews, the facility failed to ensure residents had physician orders for urinary catheters for 1 of 5 residents reviewed for urinary catheters (Resident #25), and failed to ensure staff provided appropriate catheter care that included infection control precautions for 2 of 5 residents reviewed for urinary catheters (Resident's #25 and #27). The facility reported a census of 83 residents.
Inspectors wroteBased on direct observation, clinical record review, staff and resident interview, and facility policy review, the facility failed to protect residents from significant medication errors by allowing residents who were not assessed as competent to self administer medication to do so, and by preparing and issuing medications to multiple residents simultaneous. This impacted two residents. (Resident #1, #16). The facility reported a census of 83 residents.
Inspectors wroteBased on observation, record review and staff interviews, the facility failed follow proper isolation precautions for 4 of 4 residents reviewed and failed to put on (don) an isolation gown while providing catheter care and incontinence cares for Resident #11. The facility also failed to provide personal protective equipment (PPE) for two residents that required contact precautions for Parainfluenza Virus for Resident #17, and for Clostridium difficile for Resident #29. The facility additionally failed to don PPE prior to transferring Resident #27. The facility reported a census of 83 residents.1. [...]
Inspectors wroteBased on observations, clinical record review, consultant pharmacy interview and staff interviews, the facility failed to complete routine urinary catheter care, monitor urinary output and administer an antibiotic to treat an urinary tract infection (UTI) per physician order for 2 of 3 residents (Resident #1 and Resident #11) reviewed for urinary catheter. Resident #1 did not receive a full nine-day course of antibiotics to treat an UTI which resulted in a hospitalization. The facility reported a census of 88 residents
Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to maintain a home-like environment for residents due to persistent pungent odors throughout 2 of the 3 nursing units (Station 1 and Station 2). The facility reported a census of 88.
Inspectors wroteBased on clinical record review, observation, staff interview and policy review, the facility failed to follow infection control measures in order to prevent the spread of infection for 2 of 3 residents who received insulin(an injectable medication used to lower blood sugar) (Resident #6 and #14). The facility failed to ensure staff did not utilize multiple dose insulin pens for more than one resident. The facility staff failed to perform hand hygiene and change gloves before, during, and after resident cares for 2 of 5 residents observed for cares (Resident #7 and #11). The facility also failed to ensure staff followed infection control practices to protect against cross contamination and potential spread of infection for 2 of 3 residents on Enhanced Barrier Precautions (EBP's) (Resident #7 and #11). [...]
Inspectors wroteBased on electronic health record review (EHR), observations, staff interview, and policy review, the facility failed to supervise resident administration of medications for 1 or 4 residents reviewed for medications (Resident #4). The facility reported a census of 88.
Inspectors wroteBased on clinical record review, staff interviews and policy review the facility failed to follow the physician's orders for 1 of 4 residents reviewed (Resident #3). The facility staff failed to return a [NAME] Monitor in a timely manner to the vendor after resident use which delayed downloading and analysis of the heart monitor data, follow up with the physician, and the potential treatment required. The facility reported a census of 88 residents.
Inspectors wroteBased on clinical record review, facility bath records, resident interviews, staff interviews and policy review, the facility failed to offer and provide resident bathing on a consistent basis for 3 of 5 resident reviewed for bathing (Resident #1, #3, and #5). The facility reported a census of 88.
Inspectors wroteBased on electronic health record review (EHR), staff interviews, and policy review, the facility failed to complete and document neurological exams (neuro-checks) and skin assessments for 1 of 4 residents reviewed for assessment and intervention (Resident #2). The facility reported a census of 88.
Inspectors wroteBased on clinical record review, staff and resident interviews, official city records, facility policy review, and guidance from the Centers for Medicare & Medicaid Services (CMS), the facility failed to provide necessary nursing coverage for approximately four hours on two nursing units housing a total of 53 residents, after one of two on duty nurses left the facility unscheduled. During this period of time, the facility failed to provide requested medications to three residents (Res #3, #6, #9). As a result, one resident's pain (Res #3) became so severe that she contacted 911 (emergency services) to obtain assistance with receiving her pain medication. Additionally, the facility failed to assess another resident (Res #6), who had a documented history of multiple anaphylactic reactions requiring intubation, when she reported symptoms of an allergic reaction. [...]
Inspectors wroteBased on clinical record review and staff interviews, the facility failed to complete follow up assessments following a fall for one of four residents (Res #18) reviewed for falls.
Inspectors wroteBased on clinical record review, staff interviews and review of facility policy, the facilty failed to maintain complete medical records in accordance with professional standards for three of four residents reviewed (Res #1, #13, #18).
Inspectors wroteBased on clinical record review, hospital record review, resident and staff interviews, facility education review and facility policy review, the facility failed to ensure safety during transfers for 1 of 3 residents reviewed (Resident #61). This failure caused harm when Resident #61 was improperly transferred in the shower room, resulting in a fall with two fractures. These fractures caused the resident to have an increase in pain, a need for increased pain management and a decrease in her ability to transfer. During observations of other residents, the facility additionally failed to properly use a full body mechanical lift in a safe manner and per manufacturer's instructions for Residents #4, #17 and #39. The facility reported a census of 84 residents. Findings Include: 1. [...]
Inspectors wroteBased on family and staff interviews, resident record review, and policy review, the facility failed to verify resident identity to ensure accurate resident antipsychotic medications were ordered upon admission for 1 of 3 residents reviewed (#56). The facility failed to identify the discrepancy which prevented Resident #56 from receiving antipsychotic medications for two (2) weeks. This resulted in psychosocial harm to Resident #56 due to exacerbation of psychosis, agitation, antipsychotic medication withdrawal symptoms, and subsequent hospitalization with a worsening sacral pressure ulcer. The facility reported a census of 84 residents.
Inspectors wroteBased on observation, staff interview, and policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. In addition, the facility failed to maintain the kitchen in a safe and hygienic manner that promotes food safety. The facility reported a census of 84.
Inspectors wroteBased on clinical record review, observation, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 2 of 2 residents (Residents #64, and #79) reviewed. The facility reported a census of 84 residents.
Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to properly protect resident information from unauthorized access. The facility reported a census of 84 residents.
Inspectors wrote4. On 5/15/25 at 7:11 AM, Staff B, Registered Nurse (RN) dropped a resident's medication on a report sheet on the medication cart. She picked up the medication with ungloved hands, put it back in the resident's medication cup, took it to the resident's room, and administered it to the resident. At 7:36 AM, Staff B stated she should've had gloves on or used a spoon to prepare medications. She also stated she should've never touched the medication with her hands. On 5/19/25 at 11:06 AM, the Director of Nursing (DON) stated the staff should have discarded the pill and gotten a new pill. An undated document titled Infection Control prevention directed staff to use strict aseptic technique when changing connections, accessing catheters, given IV push medications, changing bags, handling supplies, changing dressings, flushing and starting an IV. [...]
Inspectors wroteBased on observations, record review, resident and staff interview, and policy review, the facility failed to provide incontinence care at the resident's request for 1 of 23 residents (Res #81). The facility reported a census of 84 residents.
Inspectors wroteBased on observation, clinical record review, staff interviews, and policy review, the facility failed to develop a baseline care plan within 48 hours after admission for 1 of 23 residents reviewed (#60). The facility reported a census of 84 residents.
Inspectors wroteBased on observation, staff interviews, and clinical record review, the facility failed to follow the physician's orders for 1 of 23 residents (#66). The facility reported a census of 32 residents.
Inspectors wroteBased on clinical record review, observations, resident interviews, staff interviews, and policy review the facility failed to provide respiratory care and services in accordance with professional standards of practice for 2 of 4 residents reviewed (Residents #48, and #83) requiring the use of oxygen. The facility reported a census of 84 residents.
Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to include psychotropic medication target behaviors and non-pharmacologic interventions in the Care Plan for staff for 1 of 23 residents (#60). The facility reported a census of 84 residents.
Inspectors wroteBased on observation, clinical record review and staff interview, the facility failed to have a process in place for a consistent accurate count of controlled medications. This failure resulted in narcotic medications prescribed to Resident #3 becoming unaccounted for. The facility reported a census of 84 residents.
Inspectors wroteBased on observation, clinical record review, staff interview and facility policy review the facility failed to follow professional standards of practice as they allowed the Unit Managers/Supervisors to draw up liquid Morphine (pain medication) and Lorazepam (anti-anxiety medication) in one (1) milliliter (ml) syringes and placed them labeled and unlabeled in the medication carts 3 residents (Res #8, #11 and #13). The staff that drew up the medications failed to dispense the medications and were not licensed pharmacists. The facility also failed to provide sufficient detail to enable an accurate reconciliation and drug records in order to account for all controlled drugs. (Res #2 and #13) The facility identified a census of 83 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of November 11, 2024 at 3:21 p.m. [...]
Inspectors wroteBased on observation, clinical record review, staff interview and facility policy review the facility failed to allow residents to make their own choices (Resident #2) and treat 3 of 3 residents with dignity and respect when they spoke with two (2) residents (Res #7 and #18) and failed to knock and wait for an invitation to enter a residents room/home for 2 residents reviewed (Resident #1 and #2). The facility identified a census of 83 residents.
Inspectors wroteBased on observation, staff interview, resident interview and facility policy review, the facility failed to maintain call lights in reach of 4 of 4 residents reviewed. The facility identified a census of 83 residents.
Inspectors wroteBased on observation, facility record review, staff interview and facility policy review, the facility failed to provide a clean, sanitary and homelike atmosphere for the residents who resided in the facility and failed to maintain the cleanliness of resident transfer devices. The facility identified a census of 83 residents.
Inspectors wroteBased on observation, clinical record review, staff interview and facility policy review the facility failed to properly transfer one (1) resident who required an assistive device (Resident #18), failed to provide appropriate oral cares for 2 residents reviewed (Resident #4 and #11) and failed to properly groom female resident's facial hair for 1 resident (Resident #6). The facility identified a census of 83 residents.
Inspectors wroteBased on observation, clinical record review, staff interview and facility policy review, the facility staff failed to properly assess 2 of 3 following a fall, an injury and/or change of condition (Resident #5 and #8) and failed to follow Physician orders for 2 of 3 residents reviewed. (Resident #2 and #17 ) The facility identified a census of 83 residents.
Inspectors wroteBased on observation, facility pesticide invoices and staff interviews, the facility failed to provide a resident environment free of cock roaches. The facility identified a census of 83 residents.
Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed implement Care Plans for one (1) resident reviewed (Resident #6) The facility reported a census of 83 residents.
Inspectors wroteBased on clinical record review, staff interview and facility policy review, a facility staff member documented she performed a treatment for one (1) resident on the Treatment Administration Record (TAR) (Resident #10) when the treatment had not been performed. The facility identified a census of 83 residents.
Inspectors wroteBased on observation and staff interview the facility staff failed to maintain a locked and secured treatment cart and failed to provide appropriate nursing supervision to prevent a fall for one resident.(Resident #8). The facility identified a census of 83 residents.
Inspectors wroteBased on observation, clinical record review, staff interview and facility policy review the facility failed to label liquid Morphine (narcotic) and Lorazepam (anti-anxiety medications) as expected for 3 of 3 residents reviewed. (Resident #8, #11 and #13 ) The facility identified a census of 83 residents.
Inspectors wroteBased on observation, facility record review, staff interview and facility policy review, the facility staff failed to DONN (put on) Personal Protective Equipment (PPE) while they provided direct resident cares with catheters, PICC lines and open skin treatments for 3 of 3 residents reviewed (Resident #2, #10), and failed to maintain a proper catheter tubing placement as a means to prevent infection for one (1) resident reviewed. (Resident #9) The facility identified a census of 83 residents.
Inspectors wroteBased on observation, clinical record review, staff and resident interviews and policy review, the facility failed to provide assessment and intervention for the necessary care and services for 1 of 3 residents reviewed (Resident #1). The facility lacked assessments of the resident following a fall and an assessment prior to the resident being transferred to a higher level of care for evaluation and treatment. The facility reported a census of 77 residents.
Inspectors wroteBased on observation, clinical record review, staff and resident interview and policy review, the facility failed to provide treatment and services to promote the healing of a pressure ulcer for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 77 residents.
Inspectors wroteBased on observation, clinical record review, staff and resident interviews and policy review, the facility failed to provide a safe transfer for 1 of 3 residents reviewed (Resident #1). The facility failed to utilize 2 staff for a sliding board transfer as directed by the care plan resulting in a fall. The facility reported a census of 77 residents.
Inspectors wroteBased on clinical record review, observation, staff interview, and facility policy review, the facility failed to follow physician orders for 2 of 3 residents reviewed for catheter order (Residents #2 and #5). The facility reported a census of 83 residents.
Inspectors wroteBased on record review, resident interview, staff interview, collateral interview and policy review, the facility failed to assure each resident was treated with dignity and respect 1 of 2 residents reviewed for dignity (Resident #48). The facility reported a census of 80 residents.
Inspectors wroteBased on clinical record review, policy review and staff interview, the facility failed to ensure code status between the Iowa Physician's for Scope of Treatment (IPOST) and Care Plan were congruent for 1 of 1 residents reviewed for advanced directives (Resident #64). The facility reported a census of 80 residents.
Inspectors wroteBased on record review, staff interview and policy review, the facility failed to notify the physician of a change in a resident's nutritional status for 1 of 2 residents reviewed for nutrition and weight loss (Resident #6). The facility reported a census of 80 residents.
Inspectors wroteBased on record review, resident interview, staff interview, collateral interview and policy review, the facility failed to report an allegation of alleged abuse to the State survey and certification agency for 1 of 1 residents reviewed for abuse (Resident #48). The alleged abuser also continued to work with residents. The facility reported a census of 80 residents.
Inspectors wroteBased on record review, resident interview, staff interview, collateral interview and policy review, the facility failed to initiate and complete a thorough investigation of alleged abuse for 1 of 1 residents reviewed for abuse (Resident #48). The facility reported a census of 80 residents.
Inspectors wroteBased on record review, staff interview, and policy review the facility failed to notify the Long Term Care Ombudsman of discharge/transfer of residents as required for 1 of 3 residents reviewed who were discharged /transferred from the facility (Resident #26). The facility reported a census of 80 residents.
Inspectors wroteBased on clinical record review and staff interview, the facility failed to refer a resident (Resident #78) with a Level I Preadmission Screening and Resident Review (PASARR) with a diagnosed serious mental disorder for evaluation of a Level II PASARR at the time the diagnosis was known to the facility for 1 of 1 residents reviewed for PASARR. The facility reported a census of 80.
Inspectors wroteBased on record review, resident interview, staff interview and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for a resident with a urostomy and urostomy bag (a surgical procedure that creates an opening in the abdomen to redirect urine away from the bladder and into a bag outside the body for collection) for 1 of 3 residents reviewed for urinary catheter (Resident #17). The facility reported a census of 80 residents.
Inspectors wroteBased on observation, record review, resident, family, and staff interview and policy review, the facility failed to provide services that met professional standards regarding following physician orders related to flushing catheters, proper medication administration with insulin pens and allowing a resident to self-administer a cream without a physician order for 4 of 18 residents observed. (Resident #21, #40, and #61). The facility reported a census of 80 residents.
Inspectors wroteBased on observation, record review, resident interview, staff interview, and collateral interview, the facility failed to ensure a resident's environment was free from accident hazards for 1 of 1 residents reviewed for smoking (Resident #48). The facility reported a census of 80 residents.
Inspectors wroteBased on facility record review and staff interview, the facility failed to have the minimum required members present at their quarterly Quality Assurance (QA) meetings as directed by Centers for Medicare and Medicaid Services (CMS). The facility reported a census of 80 residents.
Inspectors wroteBased on observation, record review, resident interview, staff interview, collateral interview and policy review, the facility failed to establish policies regarding smoking, smoking areas, and smoking safety for 1 of 1 residents reviewed for smoking (Resident #48). The facility reported a census of 80 residents.
Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review the facility failed to perform proper hand hygiene during 2 of 3 residents (Resident #4 and #5) reviewed for wound dressing and treatments. The facility also failed to ensure resident assistive devices were maintained in a manner to keep them sanitary. The facility also failed to ensure resident's toilets were cleaned, failed to ensure the resident's drainage canisters were changed in an adequate timeframe and dated when they were changed out. The facility failed to properly wash the clothes of residents with COVID-19 and residents without COVID-19 appropriately to stop the spread of COVID-19. The facility reported a census of 80 residents.
Inspectors wroteBased on observations, staff interviews and cleaning schedule review the facility failed to maintain a safe and sanitary environment. The facility reported a census of 80 residents.
Inspectors wroteBased on observations, clinical record review, resident and staff interviews the facility failed to provide catheter drainage bag covers for 3 of 4 residents (Resident #1, #11, and #15) reviewed for dignity. The facility reported a census of 80 residents.
Inspectors wroteBased on clinical record review, observation, resident and staff interviews, provider interview, and facility policy review the facility failed to ensure 1 of 3 residents (Resident #9) reviewed for pressure ulcers received care and services to prevent pressure ulcers from forming while resided at the facility. The facility reported a census of 81 residents.
Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility staff failed to ensure a resident who needed respiratory care was provided oxygen for a doctor's appointment for 1 of 3 residents reviewed for oxygen use (Resident #4). The facility reported a census of 81 residents.
Inspectors wroteBased on clinical record review, staff interview, and facility policy review, the facility failed to ensure staff accurately recorded controlled substance medications counts, and failed to ensure proper destruction of controlled substances for 1 of 3 residents (Resident #1) reviewed for use of controlled substances. The facility also failed to ensure the facility staff documented two staff signatures to indicate they performed and witnessed the narcotic counts whenever the facility had a transition in staff for 2 of 2 medication carts reviewed. The facility reported a census of 81 residents.
Inspectors wroteBased on clinical record review, observations, resident and staff interviews, and facility policy review, the facility failed to develop comprehensive care plans for three of four residents reviewed (Resident #6, #7, and #9). The facility reported a census of 81 residents.
Inspectors wroteBased on clinical record review, observation, resident and staff interviews, and facility policy review, the facility staff failed to follow physician's orders for a treatment and dressing change performed for 1 of 3 residents reviewed for treatment and dressing changes (Resident #5). The facility also failed to follow physician's orders and ensure a resident had oxygen on when a resident was sent out of the facility to a doctor's appointment for 1 of 3 residents reviewed for oxygen use (Resident #4). The facility reported a census of 81 residents.
Inspectors wroteBased on record review, resident and staff interview along with the facility policy/procedure, the facility failed to follow physician orders for 1 of 3 residents reviewed for which the resident failed to receive their Parkinson's Disease medication for two days, this caused the resident to be admitted to the hospital with severe tremors.(Resident #2). The facility reported a census of 83 residents.
Inspectors wroteBased on clinical record review, staff interview and facility policy review, the facility failed to properly destroy Resident #6's narcotic (pain) medication per facility policy/procedure. The facility identified a census of 83 residents.
Inspectors wroteBased on record review, Medication Administration Records and Facility Policy reviews and staff interviews, the facility failed to develop a Comprehensive Care Plan that included measurable objectives and time frames related to resident specific concerns in regards to medications prescribed for 4 of 19 residents reviewed (Resident #6, #14, #73, and #71). The facility reported a census of 81 residents. Findings Include: 1. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #14 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment. The resident had diagnoses including arthritis, Parkinson's disease, bipolar disorder, anxiety disorder, atrial fibrillation, and a stroke. The resident received antidepressant, hypnotic, and opioid medications. [...]
Inspectors wroteBased on observation, Menu review, and staff interview, the facility failed to serve the appropriate portion of meat for 5 of 5 residents who received pureed meat (Resident #12, #18, #40, #51 and #52) and failed to serve the posted Menu for 4 of 4 residents who received full pureed meals (Resident #12, #18, #40 and #52). The facility reported a census of 81 residents. Findings Include: The facility's Week 3 Menu for Wednesday lunch identified the following items to be served for the meal on Wednesday, 3/29/23: a. Apple butter pork loin, 3 oz b. Stuffing, #12 scoop (2 & 2/3 oz) c. Roasted butternut squash, 4 oz Resident Diet Orders revealed 5 residents with orders for pureed texture meats and 4 residents with complete meal puree texture. During observation on 3/29/23 starting at 10:09 a.m., Staff A, [NAME] reported she was preparing six servings of pureed meat. [...]
Inspectors wroteBased on observation and employee interviews, the facility failed to properly sanitize resident dishes and utensils to prevent potential foodborne illness when the facility's dishwasher failed to heat the water to a proper temperature during the wash and rinse cycles. The facility reported a census of 81 residents. Findings Include: In the observation of meal service preparation beginning on 3/29/23 at 10:04 a.m., it was observed the dishwasher was being used to prepare for lunch service. Staff A, Cook, completed the puree process. During the puree process, she used the dishwasher multiple times to wash the measuring pitchers and the food processor bowl. When preparing for full meal service, on 3/29/23 at 10:55 a.m., the Dietary Manger reported the booster for the heat box on the dishwasher was currently broken. [...]
Inspectors wroteBased on record review and staff interview, the facility failed to provide residents or their representative the appropriate written notices when they no longer qualified for Skilled Care Services covered by Medicare for 3 of 3 residents reviewed (Resident #9, #20 and #62). The facility reported a census of 81 residents. Findings Include: 1. Resident #9's Clinical Census page showed she was on Medicare A (Skilled Care) from 11/11/22 to 12/6/22. A review of Resident #9's record showed the resident's representative signed a Notice of Medicare Non-Coverage (NOMNC) indicating her Skilled Nursing Services would end 12/5/22. Resident #9's record lacked a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was presented to the resident's representative as required. 2. Resident #20's Clinical Census page showed she was on Medicare A from 2/17/23 to 3/30/23. [...]
Inspectors wroteBased on observation, clinical record review, staff interviews and policy review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for 1 of 2 residents reviewed for nutrition (Resident #54). The facility reported a census of 81 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #54 identified a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated cognition intact. The MDS revealed the resident required setup help from staff to eat and ate independently following set up. The MDS documented diagnoses that included: end stage renal disease (kidney failure), anemia, diabetes mellitus, hyperkalemia (high potassium) and malnutrition. The MDS identified a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. [...]
Inspectors wroteBased on clinical record review, staff interview and policy review the facility failed to notify the State Long Term Care (LTC) Ombudsman for 2 of 4 residents reviewed for transfers out of the facility (Resident #2 and #20). The facility reported a census of 81 residents. Findings Include: 1. Review of the Census List for Resident #20 revealed the resident's status as on Hospital Leave on 10/25/22 and returned on 10/31/22. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 re-admitted to the facility on [DATE] from the Hospital. The facility had no documentation that staff notified the LTC Ombudsman when Resident #20 transferred from the facility to the hospital on [DATE]. The Notice of Transfer Form to LTC Ombudsman for the facility lacked documentation of Resident #20 being sent to the hospital in October 2022. [...]
21 fire safety citations on file: 12 on May 20, 2025, 5 on July 1, 2024, 4 on April 4, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| February 11, 2026 | Fine | $311,880 |
| February 11, 2026 | Payment Denial | 120 days from March 10, 2026 |
| October 22, 2025 | Fine | $16,907 |
| December 12, 2024 | Fine | $71,136 |
| December 6, 2023 | Fine | $34,223 |
| December 6, 2023 | Payment Denial | 41 days from January 3, 2024 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Iowa | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.63 | 3.82 | 3.86 |
| Registered nurses | 0.48 | 0.74 | 0.69 |
| All nursing staff on weekends | 3.30 | 3.37 | 3.42 |
| Nurse aides | 2.49 | ||
| Licensed practical nurses | 0.66 | ||
| Nursing staff turnover (share who left in a year) | 66.7% | 44.0% | 45.8% |
| Registered nurse turnover | 90.9% | 42.1% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.65 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.76 on weekdays and 3.30 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 4.1% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.39 in April to June 2025 to 3.63 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.63 | 0.48 | 3.76 | 3.30 | 4.1% | 0 of 90 | 87 |
| Oct to Dec 2025 | 3.34 | 0.26 | 3.47 | 3.00 | 1.3% | 3 of 92 | 86 |
| Jul to Sep 2025 | 3.37 | 0.46 | 3.49 | 3.08 | 1.6% | 0 of 92 | 86 |
| Apr to Jun 2025 | 3.39 | 0.42 | 3.56 | 2.97 | 2.3% | 0 of 91 | 85 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Iowa, Jan to Mar 2026 | 3.80 | 0.71 | 3.98 | 3.36 | 4.7% | 0.3% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Iowa, all employers | |||
| CNAs (nursing assistants) | $18.92 | $17.96 to $21.95 | 22,670 |
| LPNs and LVNs | $30.11 | $27.12 to $34.06 | 5,510 |
| Registered nurses | $37.80 | $32.83 to $41.32 | 34,420 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Iowa | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 16.0 | 17.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.6 | 1.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.3 | 2.4 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.7 | 3.8 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 4.7 | 2.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 23.3 | 16.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.0 | 4.2 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 20.8 | 19.4 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 15.9 | 20.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 8.0 | 13.2 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.2 | 1.5 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.3 | 2.1 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Royal Oaks Nursing and Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (56.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
56.4% this home
No different from the national rate
US median of homes 51.5% · Iowa: 28 better, 21 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 45 eligible stays.
10.3% this home
No different from the national rate
US median of homes 10.7% · Iowa: 1 better, 1 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 84 eligible stays.
6.2% this home
No different from the national rate
US median of homes 7.1% · Iowa: 0 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 41 eligible stays.
39.3% this home
Median of homes: Iowa56.7% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 28 residents counted.
5.3% this home
Median of homes: Iowa0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 38 residents counted.
2.3% this home
Median of homes: Iowa1.8% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 38 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Iowa100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 6 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: ROYAL OAKS NURSING AND REHABILITATION CENTER LLC. CMS links this home to Cedar View Holdings, a group of 9 nursing homes averaging 1.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Amaranthine Holdings LLC | 5% or greater direct ownership interest | Organization | 100% | 01/01/2025 |
| Cedar View Holdings LLC | 5% or greater indirect ownership interest | Organization | 01/01/2025 | |
| Cedar View Tr | 5% or greater indirect ownership interest | Organization | 01/01/2025 | |
| Iowa 5784 LLC | 5% or greater indirect ownership interest | Organization | 01/01/2025 | |
| Samara Family Holdings LLC | 5% or greater indirect ownership interest | Organization | 01/01/2025 | |
| Greatorex, Tina | 5% or greater indirect ownership interest | Individual | 01/01/2025 | |
| Schiowitz, Marc | 5% or greater indirect ownership interest | Individual | 01/01/2025 | |
| Sebbag, Gabriel | 5% or greater indirect ownership interest | Individual | 01/01/2025 | |
| Oconner, Michael | Operational/managerial control | Individual | 01/01/2025 | |
| Reiter, Jennifer | Operational/managerial control | Individual | 01/01/2025 | |
| Sebbag, Gabriel | Trustee of the SNF | Individual | 01/01/2025 | |
| 4614 Nw 84th Street Propco LLC | Adp of the SNF | Organization | 01/01/2025 | |
| Caresage Administrative Consulting, LLC | Adp of the SNF | Organization | 01/01/2025 | |
| Cedar View Holdings LLC | Adp of the SNF | Organization | 03/25/2025 | |
| Cedar View Tr | Adp of the SNF | Organization | 03/25/2025 | |
| Clinical Consulting Services LLC | Adp of the SNF | Organization | 01/01/2025 | |
| Iowa 5784 LLC | Adp of the SNF | Organization | 03/25/2025 | |
| Jsj 2020 Fam Tr | Adp of the SNF | Organization | 01/01/2025 | |
| Jsj Property LLC | Adp of the SNF | Organization | 01/01/2025 | |
| Samara Fam Tr | Adp of the SNF | Organization | 01/01/2025 | |
| Summation Financial Services LLC | Adp of the SNF | Organization | 01/01/2025 | |
| The Bryn Mawr Trust Company of Delaware | Adp of the SNF | Organization | 01/01/2025 | |
| Oconner, Michael | Adp of the SNF | Individual | 01/01/2025 | |
| Reiter, Jennifer | Adp of the SNF | Individual | 01/01/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Iowa. NursingHomeClear cannot take or act on complaints.