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
Staffing
Hours and turnover
RN hours / resident day
0.06
Registered nurse staffing
LPN hours / resident day
0.16
Licensed practical nurse staffing
Aide hours / resident day
1.06
Nurse aide staffing
Weekend hours
1.14
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
30%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
Nearby options
Other facilities in reach
#1
Rivercrest Post Acute
Oregon City, OR
3-star overall rating with 3-star inspections with $18,075 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Avamere Rehabilitation Of Oregon City
Oregon City, OR
3-star overall rating with 2-star inspections with $85,768 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Marquis Oregon City Post Acute Rehab
Oregon City, OR
4-star overall rating with 2-star inspections with abuse icon flag with 6 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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