Rose Haven Nursing Center
Roseburg, Oregon · CCN 385151
26 surveys since 2011, 10 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 152
- Surveys
- 26
- Harm or worse
- 10
- Immediate jeopardy
- 0
Findings where a surveyor recorded actual harm to a resident.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 193
- Ownership
- For profit - Limited Liability company
- Chain
- VOLARE HEALTH
- County
- Douglas · rural
- Medicare-certified since
- 1982
CMS ratings
- Overall
- 4
- Health inspection
- 3
- Staffing
- 4
- Quality measures
- 5
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.
Weighted by harm level, against 111 for-profit facilities in Oregon.
Last survey on record
Jun 5, 2026
157 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.59 | 4.93 |
| Registered-nurse hours per resident day | 0.73 | — |
| Annual nurse turnover | 41.5% | 41.5% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $85,105 across 2 penalties
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J— | K— | L— |
| Actual harm | G24.8% | H— | I— |
| No harm, potential for more than minimal | D2969.0% | E921.4% | F24.8% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6844×
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- F8803×
Provide and implement an infection prevention and control program.
- F5502×
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- F5842×
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.
- F6582×
Ensure services provided by the nursing facility meet professional standards of quality.
In the surveyor’s words
From the most serious findings on record at Rose Haven Nursing Center, in the surveyor’s own words.
- Actual harm, isolatedF689Feb 27, 2025
Based on observation, interview and record review it was determined the facility failed to ensure residents remained free from accident hazards for 2 of 3 sampled residents (#s 25 and 283) reviewed for accidents. Due to Staff 42 (CNA) not following the care plan, Resident 25 fell and broke her/his hip which required surgery. Findings include: 1. Resident 25 was admitted to the facility on ,d+[DATE] with acute embolism of the right lower extremity and difficulty walking. A 10/2019 Annual MDS revealed Resident 25 had a BIMS score of 7. She/he was not able to provide an interview due to impaired cognition. A review of the comprehensive care plan revised 2/3/25, indicated the resident's bed was to be in a lowered position due to her/his documented fall risk. […]
- Actual harm, isolatedF697Oct 20, 2023
Based on interview, and record review the facility failed to ensure resident's pain was managed appropriately for 2 of 6 sampled residents (#s 212 and 262) reviewed for pain management. Resident 212 experienced severe pain. Findings include: 1. Resident 212 admitted to the facility in 2021 with diagnoses including anxiety and osteoarthritis of the knee. An 8/17/21 care plan indicated Resident 212 had pain due to impaired mobility, osteoarthritis and chronic conditions with interventions which included to monitor, record and report to the nurse Resident 212's complaints of pain or requests of pain treatment. A 7/23/22 Pain evaluation indicated Resident 212 was able to verbalize her/his pain and took pain medications. […]
- Actual harm, isolatedF686Mar 28, 2022
Based on interview and record review the facility failed to ensure a resident did not develop an avoidable pressure ulcer for 1 of 3 sampled residents (#25) reviewed for pressure ulcers. This resulted in Resident 25 developing an avoidable unstageable pressure ulcer. Findings include. Resident 25 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS dated [DATE] revealed Resident 25's BIMS score was 14 which indicated she/he was cognitively intact. […]
- No harm, potential for more than minimal, widespreadF880Feb 27, 2025
Based on observation, interview and record review it was determined the facility failed to follow infection control standards for 4 of 4 halls observed and 2 of 4 sampled residents (#77 and 43) reviewed for pressure ulcers. This placed residents at risk for exposure and contraction of infectious diseases. Findings include: 1. Resident 77 was admitted to the facility in 2/2025 with diagnoses including necrotizing fasciitis (flesh eating disease), utilized a wound vac (vacuum assisted closure for healing of wounds) and a colostomy ( a surgical opening in the abdominal wall to divert stool). The CDC indicated EBP (enhanced barrier precautions) involve gown, and gloves during high contact resident care. […]
- No harm, potential for more than minimal, widespreadF575Oct 20, 2023
Based on observation and interview it was determined the facility failed to ensure Ombudsman contact and complaint filing information were posted in the facility for 1 of 1 facility reviewed for required postings. This placed residents at risk for lack of advocacy information. Findings include: During the recertification survey contact information for the Ombudsman's office and complaint reporting could not be located in a prominent and accessible location in the facility. On 10/20/23 at 9:34 AM Staff 1 (Administrator) was asked about required postings for the Ombudsman and complaint reporting information. […]
Read 28 findings in full →The most serious and the most recent: 28 of 152 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 5, 2026Standard7 findings
- Feb 27, 2025Standard and complaint11 findings · 1 harm
- Oct 20, 2023Standard and complaint15 findings · 1 harm
- Sep 23, 2022Standard and complaint9 findings
- Mar 28, 2022Complaint11 findings · 1 harm
- Mar 3, 2021Infection control1 finding
- Jan 8, 2020Complaint1 finding
- Nov 5, 2019Standard and complaint16 findings
Show the 18 earlier surveys
- Feb 27, 2019Complaint4 findings
- Apr 4, 2018Standard13 findings · 1 harm
- Nov 14, 2017Complaint2 findings · 2 harm
- May 11, 2017Complaint1 finding
- Feb 10, 2017Standard and complaint10 findings
- Nov 16, 2016Complaint2 findings · 2 harm
- May 10, 2016Complaint2 findings
- Dec 28, 2015Standard8 findings
- Nov 3, 2015Complaint2 findings
- Jul 16, 2015Complaint9 findings
- Apr 20, 2015Complaint3 findings
- Nov 7, 2014Standard4 findings
- Jun 14, 2013—3 findings
- Feb 5, 2013—2 findings
- Nov 27, 2012—1 finding
- Feb 28, 2012—9 findings
- Jul 11, 2011—3 findings · 2 harm
- Jan 13, 2011—3 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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