Rose Linn Care Center
2330 Debok Road, West Linn, OR 97068 · Clackamas County · (503) 655-0474
71 certified beds, about 61 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2014
Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
4 of 5
Staffing
1 of 5
CMS note: This facility reported a high number of days without a registered nurse onsite.
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385278 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on April 24, 2026, inspectors cited 9 health deficiencies (the Oregon average is 9.2, the national average 9.2).
None of its 14 health citations since September 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 4.04 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.26 of those hours.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
309/23
106/24
101/25
904/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 14 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
11D
2E
1F
Potential for minimal harm
0A
0B
0C
April 24, 2026Standard inspection · 9 citations
- F Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a Quality Assurance and Performance Improvement (QAPI) program implemented action plans to correct identified quality deficiencies. This placed all residents at risk for not receiving care and services for optimal resident outcomes.
- E Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNAs received annual performance reviews for 4 of 7 randomly selected CNA staff (#s 5, 6, 7, and 8) reviewed for sufficient and competent staffing. This placed residents at risk for lack of care by competent staff.
- E Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 7 of 7 randomly selected staff members (#s 5, 6, 7, 8, 9, 10, and 11) reviewed for in-service training. This placed residents at risk for lack of quality care.
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain informed consent prior to administration of a psychotropic medication for 1 of 5 sampled residents (#8) reviewed for unnecessary medications. This placed residents at risk for being uninformed of the risks and benefits of their medications.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to follow physician orders for 2 of 3 sampled residents (#s 5 and 40) reviewed for wound care and bowel medications. This placed residents at risk for constipation and worsening skin impairment.
- D 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.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to provide treatment, services, equipment, and assistance to maintain or improve mobility related to the use of a brace 1 of 1 sampled resident (#30) reviewed for mobility.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to implement care plan interventions to prevent falls for 1 of 4 sampled residents (#60) reviewed for accidents. This placed residents at risk for falls.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to properly clean a suprapubic catheter for 1 of 1 sampled resident (#5) reviewed for catheter care. This placed residents at risk for infection.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure PPE was used when wound care and catheter care was performed for 1 of 1 sampled resident (#5) reviewed for wound care. This placed residents at risk for infection.
January 31, 2025Standard inspection · 1 citation
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were provided accurate information and informed in writing of advanced beneficiary information for 2 of 2 sampled residents (#s 114 and 115) reviewed for required beneficiary notification. This placed residents at risk for not being informed of financial liabilities and the right to an appeal.
June 18, 2024Complaint inspection · 1 citation
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow the resident's plan of care to prevent a fall for 1 of 1 sampled resident (#1) reviewed for falls. This placed residents at risk for falls with injury.
September 8, 2023Standard inspection · 3 citations
- D Assist a resident in gaining access to vision and hearing services.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure treatment and services to maintain hearing abilities were provided for 2 of 2 sampled resident (#s 22 and 39) reviewed for hearing. This placed residents at risk for communication barriers and impaired hearing.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at risk for medication complications and side effects.
- D 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.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure the resident's medical record included documentation of the resident's COVID-19 vaccination status for 1 of 5 sampled residents (#39) reviewed for COVID-19 vaccine immunization. This placed residents at risk for the COVID-19 virus.
Fire safety inspections
8 fire safety citations on file: 3 on April 24, 2026, 3 on January 31, 2025, 2 on September 8, 2023.
Every fire safety citation8 citations
- E Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- D Provide properly protected cooking facilities.
- D Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- F Have simulated fire drills held at unexpected times.
- E Properly select, install, inspect, or maintain portable fire extinguishes.
- D Have proper medical gas storage and administration areas.
- D Have power receptacles that are properly grounded.
- D Ensure proper usage of power strips and extension cords.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.04 | 5.03 | 3.86 |
| Registered nurses | 0.26 | 0.72 | 0.69 |
| All nursing staff on weekends | 3.69 | 4.51 | 3.42 |
| Nurse aides | 3.00 | ||
| Licensed practical nurses | 0.78 | ||
| Nursing staff turnover (share who left in a year) | not reported | 47.4% | 45.8% |
| Registered nurse turnover | not reported | 51.6% | 42.9% |
| Administrators who left | not reported |
CMS expects 3.48 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.18 on weekdays and 3.69 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 3.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.90 in April to June 2025 to 4.04 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.04 | 0.26 | 4.18 | 3.69 | 3.8% | 4 of 90 | 61 |
| Oct to Dec 2025 | 4.05 | 0.38 | 4.19 | 3.70 | 2.5% | 1 of 92 | 62 |
| Jul to Sep 2025 | 1.28 | 0.06 | 1.34 | 1.14 | 4.9% | 63 of 92 | 62 |
| Apr to Jun 2025 | 3.90 | 0.19 | 3.90 | 3.90 | 8.1% | 2 of 91 | 64 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 4.7 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.2 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.9 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.9 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.7 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 13.4 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.3 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 32.4 | 13.9 | 15.4 |
Owners and operators
Legal business name: WEST LINN CARE CENTER OPERATING COMPANY LLC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Prudential Huntoon Paige Associates LTC Isaoa | 5% or greater mortgage interest | Organization | 07/01/2012 | |
| Benicia Senior Living LLC | Operational/managerial control | Organization | 07/01/2012 | |
| Madson, Greg | Operational/managerial control | Individual | 05/27/2025 | |
| Waldroff, Teresa | Operational/managerial control | Individual | 07/01/2012 | |
| Du Brin Corporation | Limited partnership interest | Organization | 07/01/2012 | |
| M H Zoller Co LLC | Limited partnership interest | Organization | 07/01/2012 | |
| West Linn Care Center Operating Company LLC | Limited partnership interest | Organization | 07/01/2012 | |
| Dubrin, Linda | Limited partnership interest | Individual | 07/01/2012 | |
| Geistlinger, Harry | Limited partnership interest | Individual | 07/01/2012 | |
| Waldroff, Teresa | Limited partnership interest | Individual | 07/01/2012 | |
| Zoller, Cheryl | Limited partnership interest | Individual | 07/01/2012 | |
| Zoller, Mark | Limited partnership interest | Individual | 07/01/2012 | |
| Benicia Senior Living LLC | Adp of the SNF | Organization | 10/13/2025 | |
| Du Brin Corporation | Adp of the SNF | Organization | 07/01/2012 | |
| Independence Rehab LLC | Adp of the SNF | Organization | 07/05/2022 | |
| M H Zoller Co LLC | Adp of the SNF | Organization | 07/01/2012 | |
| Prudential Huntoon Paige Associates LTC Isaoa | Adp of the SNF | Organization | 07/01/2012 | |
| West Linn Care Center Operating Company LLC | Adp of the SNF | Organization | 07/01/2012 | |
| Dubrin, Linda | Adp of the SNF | Individual | 07/01/2012 | |
| Geistlinger, Harry | Adp of the SNF | Individual | 07/01/2012 | |
| Madson, Greg | Adp of the SNF | Individual | 10/10/2025 | |
| Waldroff, Teresa | Adp of the SNF | Individual | 07/01/2012 | |
| Zoller, Cheryl | Adp of the SNF | Individual | 07/01/2012 | |
| Zoller, Mark | Adp of the SNF | Individual | 07/01/2012 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 6 problems in this area, most recently on April 24, 2026: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
- How many nurses and aides work each shift, nights and weekends included?Inspectors cited 2 problems in this area, most recently on April 24, 2026: "Observe each nurse aide's job performance and give regular training."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 2 problems in this area, most recently on April 24, 2026: "Ensure that residents are fully informed and understand their health status, care and treatments."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 2 problems in this area, most recently on April 24, 2026: "Provide and implement an infection prevention and control program."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.69 hours per resident per day, below the Oregon average of 4.51.
Other nursing homes nearby
- Rivercrest Post Acute Oregon City, 3.1 mi · 2 of 5 stars · 35 citations
- Avamere Rehabilitation of Oregon City Oregon City, 3.4 mi · 2 of 5 stars · 61 citations
- Marquis Oregon City Post Acute Rehab Oregon City, 3.7 mi · 5 of 5 stars · 13 citations
- Avamere Rehabilitation of Clackamas Gladstone, 4 mi · 4 of 5 stars · 16 citations
- Fernwood Supportive Living at Madrona Grove Portland, 5 mi · 4 of 5 stars · 19 citations
- Willamette View Health Center Milwaukie, 5.1 mi · 5 of 5 stars · 5 citations
- The Pearl at Kruse Way Lake Oswego, 5.4 mi · 4 of 5 stars · 22 citations
- Marquis Tualatin Post Acute Rehab Tualatin, 5.6 mi · 5 of 5 stars · 11 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Rose Linn Care Center's Medicare star rating?
- CMS rates Rose Linn Care Center 3 out of 5 stars overall, with 4 for health inspections, 1 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Rose Linn Care Center get at its last inspection?
- 9 health deficiencies at the standard inspection on April 24, 2026. The Oregon average is 9.2.
- Has Rose Linn Care Center been fined?
- CMS lists no fines in the last three years.
- Does Rose Linn Care Center accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Rose Linn Care Center?
- CMS lists 24 owners and managers. Legal business name: WEST LINN CARE CENTER OPERATING COMPANY LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.