Oregon ›Grants Pass

Royale Gardens Health & Rehabilitation Center

2075 NW Highland Avenue, Grants Pass, OR 97526 · Josephine County · 145 certified beds · avg 68 residents/day · certified since Apr 15, 1981

Part of chain: VOLARE HEALTH (16 facilities, chain avg rating 1.8★)

1/5
Health inspection rating (on-site)
7
Serious findings on record
$182,193
Fines, last 3 years
5.02
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Mar 13, 2026 · F-0760

The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Why it matters: A serious medication error can cause real harm, hospitalization, or worse.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Apr 29, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jan 25, 2024 · F-0603 · triggered by a complaint

The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment.

Why it matters: Forced isolation is emotionally harmful and can hide neglect or abuse from view.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 15, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jan 25, 2024 · F-0604 · triggered by a complaint

The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.

Why it matters: Unneeded restraints can cause injuries, muscle loss, and deep emotional distress.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 15, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jan 25, 2024 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 15, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jan 25, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 15, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jul 14, 2023 · F-0658

The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.

Why it matters: Care that falls below professional standards can directly harm a resident's health and recovery.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Aug 29, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jul 14, 2023 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Aug 29, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (67)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Mar 13, 2026▲ G · Actual harm, one-offThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Mar 13, 2026E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Mar 13, 2026E · Potential for harm, repeatedThe facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Mar 13, 2026D · Potential for harm, one-offThe facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences.
Mar 13, 2026D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Mar 13, 2026D · Potential for harm, one-offThe facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have.
Mar 13, 2026D · Potential for harm, one-offThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Mar 13, 2026D · Potential for harm, one-offThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Mar 13, 2026D · Potential for harm, one-offThe facility did not provide timely, approved x-ray services or have an agreement with an approved provider to supply them.
Mar 13, 2026D · Potential for harm, one-offThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jan 28, 2026E · Potential for harm, repeatedThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Jul 23, 2025D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint
Jul 23, 2025D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
May 1, 2025E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
Feb 28, 2025D · Potential for harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jan 23, 2025D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Oct 29, 2024F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Oct 29, 2024E · Potential for harm, repeatedThe facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Oct 29, 2024E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Oct 29, 2024E · Potential for harm, repeatedThe facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit.
Oct 29, 2024E · Potential for harm, repeatedThe facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule.
Oct 29, 2024E · Potential for harm, repeatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Oct 29, 2024D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint
Oct 29, 2024D · Potential for harm, one-offThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
Oct 29, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Oct 29, 2024D · Potential for harm, one-offThe facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
Oct 29, 2024D · Potential for harm, one-offThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint
Oct 29, 2024D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Oct 29, 2024D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint
Oct 29, 2024D · Potential for harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Oct 29, 2024D · Potential for harm, one-offThe facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. · from a complaint
Oct 29, 2024D · Potential for harm, one-offThe facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint
Oct 29, 2024D · Potential for harm, one-offThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Oct 29, 2024D · Potential for harm, one-offThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Oct 29, 2024D · Potential for harm, one-offThe facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
Oct 29, 2024D · Potential for harm, one-offThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Oct 29, 2024D · Potential for harm, one-offThe facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals.
Oct 29, 2024C · Minimal risk, facility-wideThe facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · from a complaint
Jan 25, 2024▲ G · Actual harm, one-offThe facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment. · from a complaint
Jan 25, 2024▲ G · Actual harm, one-offThe facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint
Jan 25, 2024▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Jan 25, 2024▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jan 25, 2024E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Jan 25, 2024E · Potential for harm, repeatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Jan 25, 2024E · Potential for harm, repeatedThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint
Jan 25, 2024D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Jan 25, 2024D · Potential for harm, one-offThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Jan 25, 2024D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Jan 25, 2024D · Potential for harm, one-offWhen a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. · from a complaint
Jan 25, 2024D · Potential for harm, one-offThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint
Jul 14, 2023▲ G · Actual harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Jul 14, 2023▲ G · Actual harm, one-offThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jul 14, 2023E · Potential for harm, repeatedThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jul 14, 2023E · Potential for harm, repeatedThe facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Jul 14, 2023E · Potential for harm, repeatedThe facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program.
Jul 14, 2023D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Jul 14, 2023D · Potential for harm, one-offThe facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences.
Jul 14, 2023D · Potential for harm, one-offThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Jul 14, 2023D · Potential for harm, one-offThe facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings.
Jul 14, 2023D · Potential for harm, one-offThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Jul 14, 2023D · Potential for harm, one-offThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Jul 14, 2023D · Potential for harm, one-offThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jul 14, 2023D · Potential for harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jul 14, 2023D · Potential for harm, one-offThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jul 14, 2023D · Potential for harm, one-offThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Jul 14, 2023D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 14, 2023D · Potential for harm, one-offThe facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (21 → 10).

YearCitationsSerious (G–L)Worst severity that year
2023172G ▲
2024344G ▲
202550E
2026111G ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

2 fines totaling $182,193.

DateTypeAmount / length
Mar 13, 2026Fine$100,580
Jan 25, 2024Fine$81,613

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityOregon avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)5.025.423.95bottom 26% in Oregon; top 13% in the U.S.
Registered Nurse hours0.570.780.69bottom 34% in Oregon; bottom 48% in the U.S.
Weekend total nurse staffing4.364.853.50bottom 22% in Oregon; top 14% in the U.S.
Weekend RN hours (not acuity-adjusted)0.170.480.48bottom 5% in Oregon; bottom 8% in the U.S.
Total nursing staff turnover (%)56.647.445.8bottom 28% in Oregon; bottom 22% in the U.S.
RN turnover (%)66.751.642.9bottom 30% in Oregon; bottom 15% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.91, RN 0.56, weekend 4.26. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Hagler, AlexanderIndividual5% or Greater Indirect Ownership Interest—03/01/2023
Knox Healthcare Pac 12 Holdings LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2023
Knox, DonaldIndividual5% or Greater Indirect Ownership Interest—03/01/2023
Pac 12 Holdings LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2023
Pac 12 Opco Holdco LLCOrganization5% or Greater Direct Ownership Interest100%03/01/2023
Pac 12 Pinnacle Holdco LLCOrganization5% or Greater Indirect Ownership Interest—03/01/2023
Gilbert Creek Propco LLCOrganization5% or Greater Mortgage InterestNOT APPLICABLE03/01/2023
Gilbert Creek Propco LLCOrganizationADP of the SNFNOT APPLICABLE03/01/2023
Hagar, ChaimIndividualADP of the SNFNOT APPLICABLE03/01/2023
Hart, KevinIndividualOperational/Managerial ControlNOT APPLICABLE08/22/2025
Hart, KevinIndividualADP of the SNFNOT APPLICABLE08/22/2025
Kahn, KarenIndividualOperational/Managerial ControlNOT APPLICABLE07/03/2023
Kahn, KarenIndividualADP of the SNFNOT APPLICABLE07/03/2023
Knox, DonaldIndividualCorporate OfficerNOT APPLICABLE03/01/2023
Knox, DonaldIndividualOperational/Managerial ControlNOT APPLICABLE03/01/2023
Knox, DonaldIndividualADP of the SNFNOT APPLICABLE03/01/2023
Pac 12 Holdings LLCOrganizationADP of the SNFNOT APPLICABLE03/01/2023
Pac 12 Pinnacle Holdco LLCOrganizationADP of the SNFNOT APPLICABLE03/01/2023
Schwartz, EliezerIndividualOperational/Managerial ControlNOT APPLICABLE03/01/2023
Schwartz, EliezerIndividualADP of the SNFNOT APPLICABLE03/01/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Highland House Nursing & Rehabilitation Center0.1 miGrants Pass, OR★☆☆☆☆1/5
Laurel Hill Nursing Center1.4 miGrants Pass, OR★★★☆☆3/5
Regency Care of Rogue Valley2.1 miGrants Pass, OR★★★★★5/5

Compare this facility with the 3 closest →

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Facility data as of CMS processing date 2026-08-01. CCN 385148.