ROYALE GARDENS HEALTH & REHABILITATION CENTER
ROYALE GARDENS HEALTH & REHABILITATION CENTER is a 145-bed nursing home in GRANTS PASS, Oregon. CMS has certified it for Medicare and Medicaid since 1981-04-15. It averages 67.7 residents a day.
What harm was found in the violations cited at ROYALE GARDENS HEALTH & REHABILITATION CENTER?
CMS lists 67 health-inspection deficiencies for ROYALE GARDENS HEALTH & REHABILITATION CENTER since 2023-07-14, 50 of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is G; the most recent health inspection was 2026-03-13.
| Survey date | Tag | Deficiency | Severity |
|---|---|---|---|
| 2026-03-13 | F0760 | Ensure that residents are free from significant medication errors. | G |
| 2026-03-13 | F0812, F0919 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. / Make sure that a working call system is available in each resident's bathroom and bathing area. | E |
| 2026-03-13 | F0553, F0554, F0676, F0679, F0688, F0776, F0842 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. / Allow residents to self-administer drugs if determined clinically appropriate. / Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. / Provide activities to meet all resident's needs. / 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. / Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D |
| 2026-01-28 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E |
| 2025-07-23 | F0552, F0600 | Ensure that residents are fully informed and understand their health status, care and treatments. / Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D |
| 2025-05-01 | F0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E |
| 2025-02-28 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D |
| 2025-01-23 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D |
| 2024-10-29 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F |
| 2024-10-29 | F0679, F0684, F0711, F0712, F0759 | Provide activities to meet all resident's needs. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. / Ensure that the resident and his/her doctor meet face-to-face at all required visits. / Ensure medication error rates are not 5 percent or greater. | E |
| 2024-10-29 | F0558, F0585, F0609, F0644, F0655, F0657, F0677, F0686, F0699, F0730, F0755, F0758, F0791, F0805, F0810 | Reasonably accommodate the needs and preferences of each resident. / 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. / Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. / Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Provide care or services that was trauma informed and/or culturally competent. / Observe each nurse aide's job performance and give regular training. / Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. / 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. / Provide or obtain dental services for each resident. / Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. / Provide special eating equipment and utensils for residents who need them and appropriate assistance. | D |
| 2024-10-29 | F0732 | Post nurse staffing information every day. | C |
| 2024-01-25 | F0603, F0604, F0686, F0689 | Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). / Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G |
| 2024-01-25 | F0584, F0684, F0908 | 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. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Keep all essential equipment working safely. | E |
| 2024-01-25 | F0609, F0610, F0656, F0661, F0690 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. / Respond appropriately to all alleged violations. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. / Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D |
| 2023-07-14 | F0658, F0686 | Ensure services provided by the nursing facility meet professional standards of quality. / Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G |
| 2023-07-14 | F0657, F0725, F0882 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. / Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. / Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | E |
| 2023-07-14 | F0550, F0553, F0554, F0557, F0558, F0625, F0656, F0689, F0695, F0806, F0880, F0947 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. / Allow resident to participate in the development and implementation of his or her person-centered plan of care. / Allow residents to self-administer drugs if determined clinically appropriate. / Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. / Reasonably accommodate the needs and preferences of each resident. / 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. / Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. / Provide safe and appropriate respiratory care for a resident when needed. / Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. / Provide and implement an infection prevention and control program. / Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | D |
Why was ROYALE GARDENS HEALTH & REHABILITATION CENTER fined 2 times?
| Date | Type | Amount |
|---|---|---|
| 2026-03-13 | Fine | $100,580 |
| 2024-01-25 | Fine | $81,613 |
How is ROYALE GARDENS HEALTH & REHABILITATION CENTER staffed relative to the OR average?
| Measure | This facility | OR average |
|---|---|---|
| Total nurse staffing hours per resident per day | 4.91152 | 5.03143 |
| Total nursing staff turnover (%) | 56.6 | 47.4 |
| Average number of residents per day | 67.7 | 58.1 |
Who owns ROYALE GARDENS HEALTH & REHABILITATION CENTER, and what chain is it in?
ROYALE GARDENS HEALTH & REHABILITATION CENTER is registered with CMS as For profit - Limited Liability company, operates under the legal business name GILBERT CREEK HEALTH & REHABILITATION CENTER LLC and belongs to the VOLARE HEALTH chain.
| Role | Owner | Association date |
|---|---|---|
| 5% OR GREATER DIRECT OWNERSHIP INTEREST | PAC 12 OPCO HOLDCO LLC | since 03/01/2023 |
| 5% OR GREATER INDIRECT OWNERSHIP INTEREST | KNOX HEALTHCARE PAC 12 HOLDINGS LLC, PAC 12 HOLDINGS LLC, PAC 12 PINNACLE HOLDCO LLC, HAGLER, ALEXANDER, KNOX, DONALD | since 03/01/2023 |
| 5% OR GREATER MORTGAGE INTEREST | GILBERT CREEK PROPCO LLC | since 03/01/2023 |
| CORPORATE OFFICER | KNOX, DONALD, SMITH, BRIAN | since 03/01/2023 |
| OPERATIONAL/MANAGERIAL CONTROL | VOLARE HEALTH LLC, HART, KEVIN, KAHN, KAREN, KNOX, DONALD, SCHWARTZ, ELIEZER | since 03/01/2023 |
| ADP OF THE SNF | GILBERT CREEK PROPCO LLC, PAC 12 HOLDINGS LLC, PAC 12 PINNACLE HOLDCO LLC, VOLARE HEALTH LLC, HAGAR, CHAIM, HART, KEVIN, KAHN, KAREN, KNOX, DONALD, SCHWARTZ, ELIEZER, SMITH, BRIAN | since 03/01/2023 |
Were you or a family member harmed at ROYALE GARDENS HEALTH & REHABILITATION CENTER?