Facility WatchInspection records for every certified US nursing home
Royale Gardens Health & Rehabilitation Center
2075 NW Highland Avenue Grants Pass, OR 97526 (541) 476-8891
CCN
385148
Certified beds
145
Ownership
For profit - Limited Liability company
Chain
Volare Health
Nurse staffing
4.77
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.52 hours per resident per day
Nursing staff turnover: 62% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected March 13, 2026
10 citations · from a complaint investigation · Health
D
F0553No actual harm with potential for more than minimal harm · Isolated
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Deficient, Provider has date of correction · corrected April 29, 2026
D
F0554No actual harm with potential for more than minimal harm · Isolated
Allow residents to self-administer drugs if determined clinically appropriate.
Deficient, Provider has date of correction · corrected April 29, 2026
D
F0676No actual harm with potential for more than minimal harm · Isolated
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Deficient, Provider has date of correction · corrected April 29, 2026
D
F0679No actual harm with potential for more than minimal harm · Isolated
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected April 29, 2026
D
F0688No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected April 29, 2026
D
F0776No actual harm with potential for more than minimal harm · Isolated
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Deficient, Provider has date of correction · corrected April 29, 2026
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected April 29, 2026
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected April 29, 2026
E
F0919No actual harm with potential for more than minimal harm · Pattern
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected April 29, 2026
G
F0760Actual harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected April 29, 2026
Inspected January 28, 2026
1 citation · from a complaint investigation · Health
E
F0812No actual harm with potential for more than minimal harm · Pattern
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected February 16, 2026
Inspected July 23, 2025
2 citations · from a complaint investigation · Health
D
F0552No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are fully informed and understand their health status, care and treatments.
Deficient, Provider has date of correction · corrected August 25, 2025
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected August 25, 2025
Inspected May 1, 2025
1 citation · from a complaint investigation · Health
E
F0725No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected June 3, 2025
Inspected February 28, 2025
1 citation · from a complaint investigation · Health
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected March 14, 2025
Inspected January 23, 2025
1 citation · from a complaint investigation · Health
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected February 28, 2025
Inspected October 29, 2024
22 citations · from a complaint investigation · Health
C
F0732No actual harm with potential for minimal harm · Widespread
Post nurse staffing information every day.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0585No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0644No actual harm with potential for more than minimal harm · Isolated
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0655No actual harm with potential for more than minimal harm · Isolated
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0657No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0699No actual harm with potential for more than minimal harm · Isolated
Provide care or services that was trauma informed and/or culturally competent.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0730No actual harm with potential for more than minimal harm · Isolated
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0758No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0791No actual harm with potential for more than minimal harm · Isolated
Provide or obtain dental services for each resident.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0805No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Deficient, Provider has date of correction · corrected December 18, 2024
D
F0810No actual harm with potential for more than minimal harm · Isolated
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Deficient, Provider has date of correction · corrected December 18, 2024
E
F0679No actual harm with potential for more than minimal harm · Pattern
Provide activities to meet all resident's needs.
Deficient, Provider has date of correction · corrected December 18, 2024
E
F0684No actual harm with potential for more than minimal harm · Pattern
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected December 18, 2024
E
F0711No actual harm with potential for more than minimal harm · Pattern
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Deficient, Provider has date of correction · corrected December 18, 2024
E
F0712No actual harm with potential for more than minimal harm · Pattern
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Deficient, Provider has date of correction · corrected December 18, 2024
E
F0759No actual harm with potential for more than minimal harm · Pattern
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected December 18, 2024
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected December 18, 2024
Inspected January 25, 2024
12 citations · from a complaint investigation · Health
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected March 15, 2024
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected March 15, 2024
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected March 15, 2024
D
F0661No actual harm with potential for more than minimal harm · Isolated
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Deficient, Provider has date of correction · corrected March 15, 2024
D
F0690No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected March 15, 2024
E
F0584No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected March 15, 2024
E
F0684No actual harm with potential for more than minimal harm · Pattern
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected March 15, 2024
E
F0908No actual harm with potential for more than minimal harm · Pattern
Keep all essential equipment working safely.
Deficient, Provider has date of correction · corrected March 15, 2024
G
F0603Actual harm · Isolated
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Deficient, Provider has date of correction · corrected March 15, 2024
G
F0604Actual harm · Isolated
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Deficient, Provider has date of correction · corrected March 15, 2024
G
F0686Actual harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected March 15, 2024
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected March 15, 2024
Inspected July 14, 2023
17 citations · from a complaint investigation · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected August 29, 2023
D
F0553No actual harm with potential for more than minimal harm · Isolated
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Deficient, Provider has date of correction · corrected August 29, 2023
D
F0554No actual harm with potential for more than minimal harm · Isolated
Allow residents to self-administer drugs if determined clinically appropriate.
Deficient, Provider has date of correction · corrected August 29, 2023
D
F0557No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Deficient, Provider has date of correction · corrected August 29, 2023
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected August 29, 2023
D
F0625No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected August 29, 2023
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected August 29, 2023
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected August 29, 2023
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected August 29, 2023
D
F0806No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Deficient, Provider has date of correction · corrected August 29, 2023
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected August 29, 2023
D
F0947No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected August 29, 2023
E
F0657No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected August 29, 2023
E
F0725No actual harm with potential for more than minimal 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.
Deficient, Provider has date of correction · corrected August 29, 2023
E
F0882No actual harm with potential for more than minimal harm · Pattern
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Deficient, Provider has date of correction · corrected August 29, 2023
G
F0658Actual harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected August 29, 2023
G
F0686Actual harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected August 29, 2023
Inspected June 7, 2023
1 citation · from a complaint investigation · Health
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected July 13, 2023
Penalties
Date
Type
Amount
January 25, 2024
Fine
$81,613
July 14, 2023
Fine
$71,065
Ownership transfers
Effective
Seller
Buyer
03/01/2023
Avalon Health Care - Royale Gardens LLC
Gilbert Creek Health & Rehabilitation Center LLC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.