Royale Gardens Health & Rehabilitation Center
Grants Pass, Josephine County, Oregon · CCN 385148 · For-profit (LLC) · part of Volare Health (16 facilities, chain average 1.8 stars)
CMS rates Royale Gardens Health & Rehabilitation Center 2 of 5 overall as of August 2026. 145 certified beds, 68 residents a day on average. 67 citations on record from the current inspection cycles, 7 involving actual harm; 2 fines totalling $182,193.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★☆☆☆☆ 1 of 5 |
| Staffing | ★★★☆☆ 3 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 5 / 4 of 5 |
Staffing
| Total nurse staffing | 4.91152 hours per resident per day |
|---|---|
| Registered nurses | 0.56069 hours per resident per day |
| Weekend total | 4.26454 hours per resident per day |
| Nursing staff turnover | 56.6% (registered nurses 66.7%) |
| Administrators who left | 2 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-03-13 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · tag F0760 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-13 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-13 complaint survey |
Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · tag F0919 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-13 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · tag F0553 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-13 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-13 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · tag F0676 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-13 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-13 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · tag F0688 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-13 | Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Administration Deficiencies · tag F0776 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-29 |
| 2026-03-13 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · tag F0842 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-29 |
| 2026-01-28 complaint survey |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-02-16 |
| 2025-07-23 complaint survey |
Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · tag F0552 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-25 |
| 2025-07-23 complaint survey |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-08-25 |
| 2025-05-01 complaint survey |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-06-03 |
| 2025-02-28 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-03-14 |
| 2025-01-23 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-28 |
| 2024-10-29 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Nursing and Physician Services Deficiencies · tag F0711 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Ensure that the resident and his/her doctor meet face-to-face at all required visits. Nursing and Physician Services Deficiencies · tag F0712 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 complaint survey |
Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Resident Rights Deficiencies · tag F0585 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · tag F0644 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 complaint survey |
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 · tag F0655 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 complaint survey |
Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 complaint survey |
Provide care or services that was trauma informed and/or culturally competent. Quality of Life and Care Deficiencies · tag F0699 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 complaint survey |
Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · tag F0730 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Pharmacy Service Deficiencies · tag F0758 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · tag F0791 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · tag F0805 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 | Provide special eating equipment and utensils for residents who need them and appropriate assistance. Nutrition and Dietary Deficiencies · tag F0810 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-12-18 |
| 2024-10-29 complaint survey |
Post nurse staffing information every day. Nursing and Physician Services Deficiencies · tag F0732 |
C No actual harm, with potential for minimal harm; widespread | Deficient, Provider has date of correction 2024-12-18 |
| 2024-01-25 complaint survey |
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0603 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-03-15 |
| 2024-01-25 complaint survey |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0604 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-03-15 |
| 2024-01-25 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-03-15 |
| 2024-01-25 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-03-15 |
| 2024-01-25 complaint survey |
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. Resident Rights Deficiencies · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-03-15 |
| 2024-01-25 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-03-15 |
| 2024-01-25 complaint survey |
Keep all essential equipment working safely. Environmental Deficiencies · tag F0908 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-03-15 |
| 2024-01-25 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-15 |
| 2024-01-25 complaint survey |
Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0610 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-15 |
| 2024-01-25 complaint survey |
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 · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-15 |
| 2024-01-25 complaint survey |
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Resident Assessment and Care Planning Deficiencies · tag F0661 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-15 |
| 2024-01-25 complaint survey |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-03-15 |
| 2023-07-14 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · tag F0657 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · tag F0725 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · tag F0882 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · tag F0553 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Resident Rights Deficiencies · tag F0557 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Resident Rights Deficiencies · tag F0625 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | 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 · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · tag F0806 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
| 2023-07-14 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · tag F0947 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-08-29 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2026-03-13 | Fine | $100,580 |
| 2024-01-25 | Fine | $81,613 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Pac 12 Opco Holdco LLC Organization | 5% or greater direct ownership interest | 100% | 2023-03-01 |
| Knox Healthcare Pac 12 Holdings LLC Organization | 5% or greater indirect ownership interest | — | 2023-03-01 |
| Pac 12 Holdings LLC Organization | 5% or greater indirect ownership interest | — | 2023-03-01 |
| Pac 12 Pinnacle Holdco LLC Organization | 5% or greater indirect ownership interest | — | 2023-03-01 |
| Gilbert Creek Propco LLC Organization | 5% or greater mortgage interest | — | 2023-03-01 |
| Gilbert Creek Propco LLC Organization | adp of the snf | — | 2023-03-01 |
| Pac 12 Holdings LLC Organization | adp of the snf | — | 2023-03-01 |
| Pac 12 Pinnacle Holdco LLC Organization | adp of the snf | — | 2023-03-01 |
| Volare Health LLC Organization | adp of the snf | — | 2025-08-19 |
| Volare Health LLC Organization | operational/managerial control | — | 2023-03-01 |
| Hagler, Alexander Individual | 5% or greater indirect ownership interest | — | 2023-03-01 |
| Knox, Donald Individual | 5% or greater indirect ownership interest | — | 2023-03-01 |
| Hagar, Chaim Individual | adp of the snf | — | 2023-03-01 |
| Hart, Kevin Individual | adp of the snf | — | 2025-08-22 |
| Kahn, Karen Individual | adp of the snf | — | 2023-07-03 |
| Knox, Donald Individual | adp of the snf | — | 2023-03-01 |
| Schwartz, Eliezer Individual | adp of the snf | — | 2023-03-01 |
| Smith, Brian Individual | adp of the snf | — | 2023-03-27 |
| Knox, Donald Individual | corporate officer | — | 2023-03-01 |
| Smith, Brian Individual | corporate officer | — | 2023-03-27 |
| Hart, Kevin Individual | operational/managerial control | — | 2025-08-22 |
| Kahn, Karen Individual | operational/managerial control | — | 2023-07-03 |
| Knox, Donald Individual | operational/managerial control | — | 2023-03-01 |
| Schwartz, Eliezer Individual | operational/managerial control | — | 2023-03-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Royale Gardens Health & Rehabilitation Center.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Josephine County.