Rose Linn Care Center

Name: Rose Linn Care Center
Address: 2330 DEBOK ROAD, West Linn, OR, 97068, US
Telephone: 5036550474

2330 Debok Road, West Linn, OR 97068 · Clackamas County · 71 certified beds · avg 61 residents/day · certified since May 3, 2014

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.45

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 3/5

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.

All citations in the current public record (14)

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
Apr 24, 2026	F · Potential for harm, facility-wide	The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Apr 24, 2026	E · Potential for harm, repeated	The facility did not observe each nurse aide's job performance or provide regular training as required.
Apr 24, 2026	E · Potential for harm, repeated	The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention.
Apr 24, 2026	D · Potential for harm, one-off	The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Apr 24, 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.
Apr 24, 2026	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.
Apr 24, 2026	D · Potential for 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.
Apr 24, 2026	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.
Apr 24, 2026	D · Potential for harm, one-off	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.
Jan 31, 2025	D · Potential for harm, one-off	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Jun 18, 2024	D · Potential for 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
Sep 8, 2023	D · Potential for harm, one-off	The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids.
Sep 8, 2023	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Sep 8, 2023	D · Potential for harm, one-off	The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (1 → 9).

Year	Citations	Worst severity that year
2023	3	D
2024	1	D
2025	1	D
2026	9	F

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)

No fines or payment denials in the published 3-year window.

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)	4.45	5.42	3.95	bottom 7% in Oregon; top 24% in the U.S.
Registered Nurse hours	0.29	0.78	0.69	bottom 2% in Oregon; bottom 8% in the U.S.
Weekend total nurse staffing	4.07	4.85	3.50	bottom 11% in Oregon; top 21% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.15	0.48	0.48	bottom 2% in Oregon; bottom 6% in the U.S.
Total nursing staff turnover (%)	0.0	47.4	45.8	—
RN turnover (%)	0.0	51.6	42.9	—

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 4.04, RN 0.26, weekend 3.69. Staffing rating: 1/5.

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: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Benicia Senior Living LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	07/01/2012
Benicia Senior Living LLC	Organization	ADP of the SNF	NOT APPLICABLE	10/13/2025
Du Brin Corporation	Organization	Limited Partnership Interest	NOT APPLICABLE	07/01/2012
Du Brin Corporation	Organization	ADP of the SNF	NOT APPLICABLE	07/01/2012
Dubrin, Linda	Individual	Limited Partnership Interest	NOT APPLICABLE	07/01/2012
Dubrin, Linda	Individual	ADP of the SNF	NOT APPLICABLE	07/01/2012
Geistlinger, Harry	Individual	Limited Partnership Interest	NOT APPLICABLE	07/01/2012
Geistlinger, Harry	Individual	ADP of the SNF	NOT APPLICABLE	07/01/2012
Independence Rehab LLC	Organization	ADP of the SNF	NOT APPLICABLE	07/05/2022
M H Zoller Co LLC	Organization	Limited Partnership Interest	NOT APPLICABLE	07/01/2012
M H Zoller Co LLC	Organization	ADP of the SNF	NOT APPLICABLE	07/01/2012
Madson, Greg	Individual	Operational/Managerial Control	NOT APPLICABLE	05/27/2025
Madson, Greg	Individual	ADP of the SNF	NOT APPLICABLE	10/10/2025
Prudential Huntoon Paige Associates LTC Isaoa	Organization	5% or Greater Mortgage Interest	NOT APPLICABLE	07/01/2012
Prudential Huntoon Paige Associates LTC Isaoa	Organization	ADP of the SNF	NOT APPLICABLE	07/01/2012
Waldroff, Teresa	Individual	Operational/Managerial Control	NOT APPLICABLE	07/01/2012
Waldroff, Teresa	Individual	Limited Partnership Interest	NOT APPLICABLE	07/01/2012
Waldroff, Teresa	Individual	ADP of the SNF	NOT APPLICABLE	07/01/2012
West Linn Care Center Operating Company LLC	Organization	Limited Partnership Interest	NOT APPLICABLE	07/01/2012
West Linn Care Center Operating Company LLC	Organization	ADP of the SNF	NOT APPLICABLE	07/01/2012

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
"How often do you evaluate your nurse aides and what ongoing training do they receive?"
"What specific training do your nurse aides complete in dementia care and abuse prevention, and how often is it refreshed?"
"How do you explain health changes and treatment options to residents and their families?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
"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
Rivercrest Post Acute	3.1 mi	Oregon City, OR	★★☆☆☆	2/5
Avamere Rehabilitation of Oregon City	3.4 mi	Oregon City, OR	★★☆☆☆	2/5
Marquis Oregon City Post Acute Rehab	3.7 mi	Oregon City, OR	★★★★★	4/5
Avamere Rehabilitation of Clackamas	4.0 mi	Gladstone, OR	★★★★☆	3/5
Fernwood Supportive Living at Madrona Grove	5.0 mi	Portland, OR	★★★★☆	3/5
Willamette View Health Center	5.1 mi	Milwaukie, OR	★★★★★	5/5
The Pearl at Kruse Way	5.4 mi	Lake Oswego, OR	★★★★☆	4/5
Marquis Tualatin Post Acute Rehab	5.6 mi	Tualatin, OR	★★★★★	4/5
Stanley Post Acute	6.4 mi	Milwaukie, OR	★★★☆☆	3/5
Marquis Wilsonville Post Acute Rehab	6.6 mi	Wilsonville, OR	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in West Linn →

Facility data as of CMS processing date 2026-08-01. CCN 385278.

The Care File

Visit checklist — Rose Linn Care Center

2330 Debok Road, West Linn, OR 97068 · 5036550474

Health inspection rating 4/5 · CMS overall 3/5· Fines (3y): $0

Questions for the administrator:

☐ "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
☐ "How often do you evaluate your nurse aides and what ongoing training do they receive?"
☐ "What specific training do your nurse aides complete in dementia care and abuse prevention, and how often is it refreshed?"
☐ "How do you explain health changes and treatment options to residents and their families?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
☐ "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?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 385278 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)