Map showing the location of ROYALE GARDENS HEALTH & REHABILITATION CENTER in GRANTS PASS, Oregon
2075 NW HIGHLAND AVENUE, GRANTS PASS, OR, 97526

Overall Score

CMS Five-Star Quality Rating
2/5Below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • OregonAbove only 17% of peers127 rated homes · average 3.0★
  • United StatesAbove only 20% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point1★−1.8 vs OR avg
  • StaffingCan add or remove a star3★−0.7 vs OR avg
  • Quality measuresCan add or remove a star5★+1.5 vs OR avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersOR avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 13% of peersOR avg3.7★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 82% of peersOR avg3.5★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff4.72hrsAbove only 31% of peersOR avg4.95Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.51hrsAbove only 35% of peersOR avg0.68Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better62%Above only 19% of peersOR avg49%RN turnover46%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$200,505Above only 2% of peersOR avg$32,647Fines · denials3 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
72citations
10inspection dates
7actual harm (G–I)
0immediate jeopardy (J–L)
Jul 23, 2025most recent

Citations by monthApr 2022 – Jul 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Jul 23, 20252 citationsCycle 1worst D · no actual harm
  1. F552Ensure that residents are fully informed and understand their health status, care and treatments.Resident RightsD · isolatedCorrected Aug 25, 2025
  2. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 25, 2025
May 1, 20251 citationCycle 1worst E · no actual harm
  1. F725Provide 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 ServicesE · patternCorrected Jun 3, 2025
Feb 28, 20251 citationCycle 1worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 14, 2025
Jan 23, 20251 citationCycle 2worst D · no actual harm
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Feb 28, 2025
Oct 29, 202422 citationsCycle 1worst F · no actual harm
  1. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Dec 18, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Dec 18, 2024
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 18, 2024
  4. F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Dec 18, 2024
  5. F657Develop 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 PlanningD · isolatedCorrected Dec 18, 2024
  6. F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Nursing and Physician ServicesE · patternCorrected Dec 18, 2024
  7. F585Honor 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 RightsD · isolatedCorrected Dec 18, 2024
  8. F679Provide activities to meet all resident's needs.Quality of Life and CareE · patternCorrected Dec 18, 2024
  9. F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Nursing and Physician ServicesE · patternCorrected Dec 18, 2024
  10. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Dec 18, 2024
  11. F758Implement 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 ServiceD · isolatedCorrected Dec 18, 2024
  12. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Dec 18, 2024
  13. F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Dec 18, 2024
  14. F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryD · isolatedCorrected Dec 18, 2024
  15. F810Provide special eating equipment and utensils for residents who need them and appropriate assistance.Nutrition and DietaryD · isolatedCorrected Dec 18, 2024
  16. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Dec 18, 2024
  17. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Dec 18, 2024
  18. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Dec 18, 2024
  19. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Dec 18, 2024
  20. F699Provide care or services that was trauma informed and/or culturally competent.Quality of Life and CareD · isolatedCorrected Dec 18, 2024
  21. F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesD · isolatedCorrected Dec 18, 2024
  22. F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Dec 18, 2024
Jan 25, 202412 citationsCycle 3worst G · actual harm$81,613
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Mar 15, 2024
  2. F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Resident Assessment and Care PlanningD · isolatedCorrected Mar 15, 2024
  3. F584Honor 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 RightsE · patternCorrected Mar 15, 2024
  4. F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Mar 15, 2024
  5. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Mar 15, 2024
  6. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 15, 2024
  7. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 15, 2024
  8. F656Develop 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 PlanningD · isolatedCorrected Mar 15, 2024
  9. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareE · patternCorrected Mar 15, 2024
  10. F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected Mar 15, 2024
  11. F690Provide 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 CareD · isolatedCorrected Mar 15, 2024
  12. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Mar 15, 2024
Jul 14, 202317 citationsCycle 2worst G · actual harm$71,065
  1. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 29, 2023
  2. 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 RightsD · isolatedCorrected Aug 29, 2023
  3. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Aug 29, 2023
  4. F553Allow resident to participate in the development and implementation of his or her person-centered plan of care.Resident RightsD · isolatedCorrected Aug 29, 2023
  5. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Aug 29, 2023
  6. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Aug 29, 2023
  7. F656Develop 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 PlanningD · isolatedCorrected Aug 29, 2023
  8. F657Develop 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 PlanningE · patternCorrected Aug 29, 2023
  9. F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningG · isolatedCorrected Aug 29, 2023
  10. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareG · isolatedCorrected Aug 29, 2023
  11. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Aug 29, 2023
  12. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Aug 29, 2023
  13. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Aug 29, 2023
  14. F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlE · patternCorrected Aug 29, 2023
  15. F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Aug 29, 2023
  16. F725Provide 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 ServicesE · patternCorrected Aug 29, 2023
  17. F947Ensure 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 ServicesD · isolatedCorrected Aug 29, 2023
Jun 7, 20231 citationCycle 3worst D · no actual harm
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jul 13, 2023
Apr 12, 20237 citationsCycle 3worst G · actual harm$47,827
  1. F656Develop 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 PlanningE · patternCorrected May 25, 2023
  2. F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.Resident Assessment and Care PlanningD · isolatedCorrected May 25, 2023
  3. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected May 25, 2023
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected May 25, 2023
  5. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jul 13, 2022
  6. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected May 25, 2023
  7. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 25, 2023
Apr 9, 20228 citationsCycle 3worst F · no actual harm
  1. F657Develop 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 PlanningD · isolatedCorrected May 29, 2022
  2. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 29, 2022
  3. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected May 29, 2022
  4. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected May 29, 2022
  5. F584Honor 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 RightsE · patternCorrected May 29, 2022
  6. F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningE · patternCorrected May 29, 2022
  7. F656Develop 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 PlanningE · patternCorrected May 29, 2022
  8. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected May 29, 2022

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined4.72hrsAbove only 31% of peers−0.23 vs OR avg
  • Registered nursesRN hours only0.51hrsAbove only 35% of peers−0.17 vs OR avg
  • Licensed practical nursesLPN hours0.86hrs
  • Nurse aidesCNA hours3.35hrs
  • Weekend nursingAll staff on Saturdays and Sundays4.14hrs
  • Oregon average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better62%Above only 19% of peersOR avg 49%
  • RN turnoverRegistered nurses only46%Not ranked by CMS
  • Administrators who leftIn the past year1Leadership changed
  • Occupancy145 certified beds · ~71 residents a day49%Above only 17% of peersOR avg 69%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $200,505In fines
  • 3Fines
  • 0Payment denials
  • $32,647OR avg in fines
Above only 2% of peersFewer fines than 2% of rated homes in Oregon

Actions on record

  1. Jan 25, 2024Civil money penalty$81,613
  2. Jul 14, 2023Civil money penalty$71,065
  3. Apr 12, 2023Civil money penalty$47,827

Ownership

As filed with CMS

Structure

Ownership type
For profit - Corporation
Chain
Volare Health16 facilities in the chain1.6★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Pac 12 Opco Holdco LLC
Indirect owners (5%+)
  • Knox Healthcare Pac 12 Holdings LLC
  • Pac 12 Holdings LLC
  • Pac 12 Pinnacle Holdco LLC
  • Chaim Hagar
  • Alexander Hagler
  • Donald Knox
  • Eliezer Schwartz
Operational or managerial control
  • Pac 12 Opco Holdco LLC
  • Pac 12 Pinnacle Holdco LLC
  • Volare Health LLC
  • Eliezer Schwartz
Corporate officers
  • Donald Knox
  • Benjamin Sparks

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 385148 · 2075 NW HIGHLAND AVENUE, GRANTS PASS, OR, 97526.
  • Percentiles compare this facility with every rated nursing home in Oregon and Josephine County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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