Cycle 1
Health 2025-01-31 · Fire 2025-01-31
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
West Linn, OR
Rose Linn Care Center
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2330 Debok Road, West Linn, OR
(503) 655-0474
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
71
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2014-05-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.06
Registered nurse staffing · state 0.68 · national 0.68
LPN hours / resident day
0.16
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.06
Nurse aide staffing · state 3.37 · national 2.35
Total nurse hours
1.28
All reported nurse hours · state 4.95 · national 3.89
Licensed hours
0.22
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
1.14
Weekend nurse staffing · state 4.39 · national 3.43
Weekend RN hours
0.05
Weekend registered nurse coverage · state 0.44 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.07
CMS adjusted RN staffing hours
Adjusted total hours
1.44
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
30%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,320
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.58
Composite VBP score used to determine payment impact.
Payment multiplier
1.0128
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
9.46
Baseline 20.93% · Performance 25.00% · Measure score 9.46 · Achievement 9.46 · Improvement 0
Adjusted total nurse staffing
2.05
Baseline 3.70 hours · Performance 3.66 hours · Measure score 2.05 · Achievement 2.05 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 5 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 6.93% |
8.2%
1.3 pts worse
|
Numerator 7 · Denominator 101 |
| Staff flu vaccination coverage | 15% |
42%
27 pts worse
|
Numerator 15 · Denominator 100 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.4% |
95.5%
8.1 pts worse
|
93.4%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 84.7% · Q3 85.2% · Q4 88.3% · 4Q avg 87.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.5% |
95.2%
0.3 pts better
|
95.5%
About the same
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
2.4%
1.8 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 5.1% · Q3 4.9% · Q4 5.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.7%
4.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
5.0%
1.7 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 3.8% · Q3 1.9% · Q4 1.8% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
12.5%
4.5 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 9.6% · Q3 9.4% · Q4 9.1% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 35.6% |
14.7%
20.9 pts worse
|
16.7%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 32.6% · Q3 38.8% · Q4 35.6% · 4Q avg 35.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.5% |
24.1%
9.6 pts better
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 8.4% · Q3 19.2% · Q4 12.7% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.4% |
15.8%
8.4 pts better
|
14.9%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.0% · Q3 4.5% · Q4 12.8% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
1.7%
0.1 pts better
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 1.5% · Q4 1.7% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
2.0%
1.3 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.8% · Q3 1.6% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
22.2%
6.7 pts better
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 18.3% · Q3 6.7% · Q4 17.3% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
6.5%
2.9 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.3% · Q3 2.8% · Q4 4.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.2% |
85.4%
21.2 pts worse
|
81.7%
17.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.5% · Q2 60.0% · Q3 65.2% · Q4 70.4% · 4Q avg 64.2% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.7%
1.5 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 25.8% |
81.2%
55.4 pts worse
|
79.7%
53.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 25.8% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-08 · Fire 2023-09-08
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-08-01 · Fire 2022-08-01
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-21
E · Potential for more than minimal harm
2025-01-31
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-01-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-21
D · Potential for more than minimal harm
2023-09-08
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-27
F · Potential for more than minimal harm
2022-08-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-09-13
F · Potential for more than minimal harm
2022-08-01
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-09-13
D · Potential for more than minimal harm
2022-08-01
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-09-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-31
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-21
D · Potential for more than minimal harm
2024-06-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-03
D · Potential for more than minimal harm
2023-09-08
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-08
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-08
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-10-27
G · Actual harm
2022-08-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-09-20
G · Actual harm
2022-08-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-20
F · Potential for more than minimal harm
2022-08-01
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-09-20
E · Potential for more than minimal harm
2022-08-01
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-09-20
E · Potential for more than minimal harm
2022-08-01
F688 · Quality of Life and Care Deficiencies
Health
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 2022-09-20
E · Potential for more than minimal harm
2022-08-01
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-01
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-01
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-01
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-01
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-09-20
D · Potential for more than minimal harm
2022-08-01
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2022-09-20
Penalties and ownership
What sits behind the stars
Ownership
Geistlinger, Harry
5% Or Greater Indirect Ownership Interest · Individual
Waldroff, Teresa
5% Or Greater Indirect Ownership Interest · Individual
Zoller, Mark
5% Or Greater Indirect Ownership Interest · Individual
Dubrin, Linda
5% Or Greater Direct Ownership Interest · Individual
Dubrin, Linda
5% Or Greater Indirect Ownership Interest · Individual
Zoller, Cheryl
5% Or Greater Indirect Ownership Interest · Individual
Benicia Senior Living LLC
Operational/Managerial Control · Organization
Contemporary Healthcare Fund I, LP
5% Or Greater Mortgage Interest · Organization
Contemporary Healthcare Senior Lien Fund I, LP
5% Or Greater Mortgage Interest · Organization
Ouellette, Sandra
5% Or Greater Direct Ownership Interest · Individual
Waldroff, Teresa
Operational/Managerial Control · Individual
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