Rose Haven Nursing Center
740 NW Hill, Roseburg, OR 97471 · Douglas County · 193 certified beds · avg 81 residents/day · certified since May 12, 1982
Part of chain: VOLARE HEALTH (16 facilities, chain avg rating 1.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 27, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 3, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Oct 20, 2023 · F-0697 · triggered by a complaint
The facility did not provide safe and appropriate pain management for a resident who needed it.
Why it matters: Untreated pain causes needless suffering and can lead to depression, poor sleep, and declining health.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 5, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (33)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 5, 2026 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jun 5, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 5, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jun 5, 2026 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Jun 5, 2026 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jun 5, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 5, 2026 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Feb 27, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 27, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Feb 27, 2025 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Feb 27, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Feb 27, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 27, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 27, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Feb 27, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Feb 27, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Feb 27, 2025 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Feb 27, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint |
| Oct 20, 2023 | ▲ G · Actual harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| Oct 20, 2023 | F · Potential for harm, facility-wide | The facility did not post the names, addresses, and phone numbers of state agencies and advocacy groups, along with a notice that residents may file complaints with the state survey agency. |
| Oct 20, 2023 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 20, 2023 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Oct 20, 2023 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · from a complaint |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Oct 20, 2023 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (11 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 15 | 1 | G ▲ |
| 2025 | 11 | 1 | G ▲ |
| 2026 | 7 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $85,105.
| Date | Type | Amount / length |
|---|---|---|
| Feb 27, 2025 | Fine | $33,716 |
| Oct 20, 2023 | Fine | $51,389 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Oregon avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.37 | 5.42 | 3.95 | bottom 3% in Oregon; top 27% in the U.S. |
| Registered Nurse hours | 0.70 | 0.78 | 0.69 | top 48% in Oregon; top 37% in the U.S. |
| Weekend total nurse staffing | 3.89 | 4.85 | 3.50 | bottom 3% in Oregon; top 26% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.36 | 0.48 | 0.48 | bottom 42% in Oregon; bottom 44% in the U.S. |
| Total nursing staff turnover (%) | 41.5 | 47.4 | 45.8 | top 33% in Oregon; top 40% in the U.S. |
| RN turnover (%) | 38.5 | 51.6 | 42.9 | top 24% in Oregon; top 44% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.59, RN 0.73, weekend 4.09. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Hagler, Alexander | Individual | 5% or Greater Indirect Ownership Interest | — | 03/01/2023 |
| Knox Healthcare Pac 12 Holdings LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 03/01/2023 |
| Knox, Donald | Individual | 5% or Greater Indirect Ownership Interest | — | 03/01/2023 |
| Pac 12 Holdings LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 03/01/2023 |
| Pac 12 Opco Holdco LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/01/2023 |
| Pac 12 Pinnacle Holdco LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 03/01/2023 |
| Fisher, Joshua | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2025 |
| Fisher, Joshua | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2025 |
| Hagar, Chaim | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2023 |
| Knox, Donald | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2023 |
| Knox, Donald | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2023 |
| Knox, Donald | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2023 |
| Pac 12 Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2023 |
| Pac 12 Pinnacle Holdco LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/01/2023 |
| Rust, Kira | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2023 |
| Rust, Kira | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2023 |
| Schwartz, Eliezer | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2023 |
| Schwartz, Eliezer | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2023 |
| Smith, Brian | Individual | Corporate Officer | NOT APPLICABLE | 03/27/2023 |
| Smith, Brian | Individual | ADP of the SNF | NOT APPLICABLE | 03/27/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How soon after admission is a full assessment completed, and how are the findings shared with the family?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Umpqua Valley Nursing & Rehabilitation Center | 0.9 mi | Roseburg, OR | ★★★★☆ | 3/5 |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 385151.