Royale Gardens Health & Rehabilitation Center
2075 Nw Highland Avenue · Grants Pass, OR · 97526 · 5414768891
145 certified beds For profit - Limited Liability company Chain: Volare Health
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- 7 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
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Red flags
2 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
62% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 4.83 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.53 | 0.55–0.75 |
| Weekend hours / resident-day | 4.35 | ≈ weekday level |
| Nursing turnover / year | 62% | median 45% |
| Fines (3-yr window) | 2 · $152,678 |
Inspection citations (68 in the current record)
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Actual harm · G March 13, 2026
Ensure that residents are free from significant medication errors.
Corrected April 29, 2026 · Pharmacy Service
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Potential for harm · D March 13, 2026
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected April 29, 2026 · Resident Rights
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Potential for harm · D March 13, 2026
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected April 29, 2026 · Resident Rights
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Potential for harm · D March 13, 2026
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected April 29, 2026 · Quality of Life and Care
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Potential for harm · D March 13, 2026
Provide activities to meet all resident's needs.
Corrected April 29, 2026 · Quality of Life and Care
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Potential for harm · D March 13, 2026
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.
Corrected April 29, 2026 · Quality of Life and Care
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Potential for harm · D March 13, 2026
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected April 29, 2026 · Administration
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Potential for harm · E March 13, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 29, 2026 · Nutrition and Dietary
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Potential for harm · D March 13, 2026
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected April 29, 2026 · Resident Assessment and Care Planning
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Potential for harm · E March 13, 2026 · found via complaint
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected April 29, 2026 · Environmental
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Potential for harm · E January 28, 2026 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 16, 2026 · Nutrition and Dietary
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Potential for harm · D July 23, 2025 · found via complaint
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected August 25, 2025 · Resident Rights
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Potential for harm · D July 23, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 25, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E May 1, 2025 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected June 3, 2025 · Nursing and Physician Services
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Potential for harm · D February 28, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 14, 2025 · Quality of Life and Care
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Potential for harm · D January 23, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 28, 2025 · Quality of Life and Care
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Potential for harm · D October 29, 2024 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected December 18, 2024 · Resident Rights
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Potential for harm · D October 29, 2024
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.
Corrected December 18, 2024 · Resident Rights
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Potential for harm · D October 29, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 18, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 29, 2024
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected December 18, 2024 · Resident Assessment and Care Planning
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Potential for harm · D October 29, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected December 18, 2024 · Resident Assessment and Care Planning
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Potential for harm · E October 29, 2024
Provide activities to meet all resident's needs.
Corrected December 18, 2024 · Quality of Life and Care
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Potential for harm · E October 29, 2024
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected December 18, 2024 · Nursing and Physician Services
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Potential for harm · E October 29, 2024
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected December 18, 2024 · Nursing and Physician Services
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Potential for harm · D October 29, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected December 18, 2024 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| January 25, 2024 | Fine | $81,613 |
| July 14, 2023 | Fine | $71,065 |
Better-scoring options nearby
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385148 · certified since April 15, 1981. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.