F59

ROYALE GARDENS HEALTH & REHABILITATION CENTER

Grade F 59/100 composite score

For profit - CorporationSFF CandidateAbuse Citation

CMS Star Ratings

Overall
2/5
Health Insp.
1/5
Quality
5/5
Staffing
3/5
RN Staffing
Not rated

Certified Beds

145

Ownership

For profit - Corporation

Total Fines

$200,505

Last Survey

N/A

2075 NW HIGHLAND AVENUE, GRANTS PASS, OR 97526
5414768891

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.51h
LPN
0.86h
CNA
3.36h
Total
4.73h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

PAC 12 OPCO HOLDCO LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jan 2023

100%

KNOX HEALTHCARE PAC 12 HOLDINGS LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2023

PAC 12 HOLDINGS LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2023

PAC 12 PINNACLE HOLDCO LLC

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2023

HAGAR, CHAIM

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2023

HAGLER, ALEXANDER

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2023

KNOX, DONALD

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2023

SCHWARTZ, ELIEZER

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Jan 2023

PAC 12 OPCO HOLDCO LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 2023

PAC 12 PINNACLE HOLDCO LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 2023

VOLARE HEALTH LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 2023

SCHWARTZ, ELIEZER

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Jan 2023

KNOX, DONALD

IndividualCORPORATE OFFICERSince Jan 2023

SPARKS, BENJAMIN

IndividualCORPORATE OFFICERSince Jan 2023

Penalties & Fines (3)

$200,505total fines
DateTypeDescriptionAmount
Jan 25, 2024Fine$81,613
Jul 14, 2023Fine$71,065
Apr 12, 2023Fine$47,827

Health Inspection Deficiencies (73)

July 23, 2025Health2 deficiencies
0552DMinimal harm, Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Corrected Aug 25, 2025
0600DMinimal harm, Isolated

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

Corrected Aug 25, 2025
May 1, 2025Health1 deficiency
0725EMinimal harm, Pattern

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

Corrected Jun 3, 2025
February 28, 2025Health1 deficiency
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Mar 14, 2025
January 23, 2025Health1 deficiency
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Feb 28, 2025
October 29, 2024Health23 deficiencies2 severe
0585DMinimal harm, Isolated

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

Corrected Dec 18, 2024
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Dec 18, 2024
0676DMinimal harm, Isolated

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

Corrected Dec 18, 2024
0679EMinimal harm, Pattern

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected Dec 18, 2024
0755JImmediate jeopardy, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Dec 18, 2024
0805EMinimal harm, Pattern

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies

Corrected Dec 18, 2024
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Dec 18, 2024
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Dec 18, 2024
0684EMinimal harm, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Dec 18, 2024
0699DMinimal harm, Isolated

Provide care or services that was trauma informed and/or culturally competent.

Quality of Life and Care Deficiencies

Corrected Dec 18, 2024
0730DMinimal harm, Isolated

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies

Corrected Dec 18, 2024
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Dec 18, 2024
0655DMinimal harm, Isolated

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

Corrected Dec 18, 2024
0657DMinimal harm, Isolated

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

Corrected Dec 18, 2024
0686GActual harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Dec 18, 2024
0711EMinimal harm, Pattern

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

Corrected Dec 18, 2024
0712EMinimal harm, Pattern

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Nursing and Physician Services Deficiencies

Corrected Dec 18, 2024
0732EMinimal harm, Pattern

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies

Corrected Dec 18, 2024
0758DMinimal harm, Isolated

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

Corrected Dec 18, 2024
0759EMinimal harm, Pattern

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Dec 18, 2024
0791DMinimal harm, Isolated

Provide or obtain dental services for each resident.

Quality of Life and Care Deficiencies

Corrected Dec 18, 2024
0810DMinimal harm, Isolated

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Nutrition and Dietary Deficiencies

Corrected Dec 18, 2024
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Dec 18, 2024
January 25, 2024Health12 deficiencies4 severe
0603GActual harm, Isolated

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 15, 2024
0604GActual harm, Isolated

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 15, 2024
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 15, 2024
0656DMinimal harm, Isolated

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

Corrected Mar 15, 2024
0684EMinimal harm, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Mar 15, 2024
0686GActual harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Mar 15, 2024
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Mar 15, 2024
0908EMinimal harm, Pattern

Keep all essential equipment working safely.

Environmental Deficiencies

Corrected Mar 15, 2024
0584EMinimal harm, Pattern

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

Corrected Mar 15, 2024
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Mar 15, 2024
0661DMinimal harm, Isolated

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

Corrected Mar 15, 2024
0690DMinimal harm, Isolated

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

Corrected Mar 15, 2024
July 14, 2023Health17 deficiencies2 severe
0553DMinimal harm, Isolated

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Resident Rights Deficiencies

Corrected Aug 29, 2023
0656DMinimal harm, Isolated

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

Corrected Aug 29, 2023
0657EMinimal harm, Pattern

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

Corrected Aug 29, 2023
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Aug 29, 2023
0882EMinimal harm, Pattern

Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Infection Control Deficiencies

Corrected Aug 29, 2023
0725EMinimal harm, Pattern

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

Corrected Aug 29, 2023
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Aug 29, 2023
0947DMinimal harm, Isolated

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

Corrected Aug 29, 2023
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Aug 29, 2023
0557DMinimal harm, Isolated

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Resident Rights Deficiencies

Corrected Aug 29, 2023
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Aug 29, 2023
0625DMinimal harm, Isolated

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

Corrected Aug 29, 2023
0658GActual harm, Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Aug 29, 2023
0686GActual harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Aug 29, 2023
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Aug 29, 2023
0806DMinimal harm, Isolated

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

Corrected Aug 29, 2023
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Aug 29, 2023
June 7, 2023Health1 deficiency
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Jul 13, 2023
April 12, 2023Health7 deficiencies1 severe
0600DMinimal harm, Isolated

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

Corrected Jul 13, 2022
0661DMinimal harm, Isolated

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

Corrected May 25, 2023
0684GActual harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected May 25, 2023
0610DMinimal harm, Isolated

Respond appropriately to all alleged violations.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected May 25, 2023
0636DMinimal harm, Isolated

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies

Corrected May 25, 2023
0656EMinimal harm, Pattern

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

Corrected May 25, 2023
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected May 25, 2023
April 9, 2022Health8 deficiencies
0636EMinimal harm, Pattern

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Resident Assessment and Care Planning Deficiencies

Corrected May 29, 2022
0695EMinimal harm, Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected May 29, 2022
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected May 29, 2022
0584EMinimal harm, Pattern

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

Corrected May 29, 2022
0656EMinimal harm, Pattern

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

Corrected May 29, 2022
0657DMinimal harm, Isolated

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

Corrected May 29, 2022
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected May 29, 2022
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected May 29, 2022

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Frequently Asked Questions

What is the CareGrader rating for ROYALE GARDENS HEALTH & REHABILITATION CENTER?

ROYALE GARDENS HEALTH & REHABILITATION CENTER in GRANTS PASS, Oregon has a CareGrader grade of F (Poor), with a composite score of 59 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for ROYALE GARDENS HEALTH & REHABILITATION CENTER?

ROYALE GARDENS HEALTH & REHABILITATION CENTER has an overall CMS star rating of 2 out of 5, a health inspection rating of 1/5, and a staffing rating of 3/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does ROYALE GARDENS HEALTH & REHABILITATION CENTER have?

ROYALE GARDENS HEALTH & REHABILITATION CENTER has 73 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). This facility has abuse citations on record. View the full inspection timeline above for details on each deficiency.

Has ROYALE GARDENS HEALTH & REHABILITATION CENTER been fined?

Yes. ROYALE GARDENS HEALTH & REHABILITATION CENTER has $200,505 in total fines from CMS enforcement actions across 3 penalties.

How many beds does ROYALE GARDENS HEALTH & REHABILITATION CENTER have?

ROYALE GARDENS HEALTH & REHABILITATION CENTER has 145 certified beds with approximately 70 current residents (48% occupancy). The facility is located at 2075 NW HIGHLAND AVENUE, GRANTS PASS, Oregon 97526. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.