Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rose Linn Care Center during CMS and state inspections, most recent first.
The facility’s QAPI program did not address multiple identified quality deficiencies. An Interim Administrator acknowledged that the program failed to recognize issues involving consent for psychotropic meds, implementation of physician orders for wound care, mobility, and bowel meds, fall prevention care plans, nurse aide performance reviews and required in-service training, and infection control practices tied to CDC guidelines.
Missing Annual CNA Performance Reviews: The facility failed to ensure annual performance reviews were completed for 4 of 7 CNAs reviewed. Record review showed multiple CNAs had performance evaluations completed outside the expected annual timeframe, and the Interim Administrator acknowledged the reviews were not completed annually.
The facility failed to ensure CNAs completed the required 12 hours of annual in-service training for 7 of 7 staff reviewed. Meeting minutes and sign-in sheets showed attendance at all-staff meetings, but the records did not identify the training topics or how many hours each CNA received, and the HR/Payroll Director could not produce documentation showing the required training hours were completed. The Administrator acknowledged the annual CNA in-service requirement was not met.
Failure to obtain informed consent before giving a psychotropic medication. A resident with depression and dementia was prescribed sertraline and received it daily, but the medical record showed no indication the resident was informed in advance of the risks and benefits. An LPN Resident Care Manager acknowledged the resident was not informed of the risks and benefits of sertraline.
Failure to follow bowel and wound care orders. A resident with bowel incontinence and total toileting dependence went 5 days without a BM, but ordered PRN constipation meds and the bowel routine were not followed. Another resident with a BIMS of 1 had elbow wound care orders that were not carried out as written; one dressing was left on past the expected time and the other wound was observed exposed, with staff later acknowledging the wound care was not completed as documented.
A resident with gait and mobility problems, cognitive impairment, and an AFO ordered for ankle weakness and instability was not consistently offered or assisted with brace use and restorative transfer programs. The resident reported the brace caused pain and had not been reassessed for fit, while staff gave conflicting reports about whether the AFO was required, whether refusals were documented, and whether the brace had been properly assessed after adjustment.
Failure to keep a high fall risk resident’s call light within reach. A resident with a stroke, femur fx, and cognitive impairment had a care plan for 1-person assist with transfers and call light access, but was observed multiple times with the call light draped over the bed and out of reach. The resident had two unwitnessed falls related to attempts to self-transfer, and staff acknowledged the resident was forgetful and that it was not safe to ambulate in a wheelchair around the bed to reach the call light.
Improper suprapubic catheter care was observed for a resident with acute cystitis and significant cognitive impairment. Staff cleaned the catheter site with warm water only instead of the ordered warm soapy water or other gentle cleanser, and the staff member acknowledged she forgot to follow the order. An LPN Resident Care Manager stated staff were to follow the catheter care orders.
Failure to use PPE during wound care and catheter care was cited for a resident with acute cystitis and a BIMS score of 1. Staff emptied a suprapubic catheter bag without PPE and later removed and changed elbow dressings without PPE, with staff stating PPE was not needed because they were not touching the catheter or because the resident did not have a urine infection.
The facility failed to provide complete and accurate Notice of Medicare Non-Coverage (NOMNC) forms to two residents, resulting in a lack of information regarding their Medicare coverage and potential financial liabilities. One resident received an incomplete NOMNC form, while another did not receive any form at all, as confirmed by the Social Services Director.
A resident with dementia, requiring a Hoyer lift and two-person assistance for transfers, was improperly transferred by a CNA using a Sara lift, leading to a fall and injury. The CNA acted alone, contrary to the care plan, and was terminated following the incident.
QAPI Program Failed to Address Identified Quality Deficiencies
Penalty
Summary
The facility failed to ensure its QAPI program implemented action plans to correct identified quality deficiencies. The report states that the facility’s QAPI program was intended to support safety, high quality clinical interventions, service delivery, autonomy, choice, and quality of daily life through data collection tools and monitoring systems, but interview and record review showed the program did not recognize or address several concerns. Staff 1, the Interim Administrator, acknowledged that the QAPI program did not address obtaining consent when psychotropic medications were used, implementing physician orders related to wound care, mobility, and bowel medications, implementing care plans to prevent falls, nurse aide performance reviews and required in-service training, and infection control practices related to following CDC guidelines.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure CNAs received annual performance reviews for 4 of 7 randomly selected CNA staff reviewed for sufficient and competent staffing. Personnel record review on 4/24/26 showed that Staff 5, a CNA hired in 11/2020, had a performance review completed in 11/2024; Staff 6, a CNA hired in 8/2023, had a performance review completed in 8/2024; Staff 7, a CNA hired in 11/2011, had a performance review completed in 11/2024; and Staff 8, a CNA hired in 1/2015, had a performance review completed in 1/2025. On 4/24/26 at 10:43 AM, Staff 1, the Interim Administrator, stated performance reviews were to be completed annually and acknowledged that annual performance reviews were not completed for Staff 5, Staff 6, Staff 7, and Staff 8.
CNA Annual In-Service Training Not Completed
Penalty
Summary
The facility failed to ensure CNA staff received the required 12 hours of annual in-service training for 7 of 7 randomly selected staff members (#5, 6, 7, 8, 9, 10, and 11) reviewed for in-service training. During record review, the Human Resources/Payroll Director provided minutes and sign-in sheets for all-staff meetings from 4/2025 through 4/2026, which showed these CNAs attended various meetings, but the records did not identify what topics were covered or how many hours of training were provided. The Human Resources/Payroll Director stated staff were expected to attend all-staff meetings to receive the required trainings, and if they were absent they received a packet of the materials covered, but no record could be produced showing the topics covered or the number of hours each CNA attended or received. The Administrator acknowledged that the 12 hours of annual in-service training for CNAs was not completed.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent before administering sertraline, a psychotropic antidepressant, to Resident 8. Resident 8 was admitted in 3/2026 with diagnoses including depression and dementia, and the 3/2026 physician orders showed sertraline was prescribed for depression. The 4/2026 MAR showed the resident received sertraline daily, but review of the medical record found no indication that the resident was informed in advance of the risks and benefits of sertraline. On 4/23/26 at 1:24 PM, Staff 3, the LPN Resident Care Manager, acknowledged that Resident 8 was not informed of the risks and benefits for the use of sertraline.
Failure to Follow Bowel and Wound Care Orders
Penalty
Summary
The facility failed to follow physician orders for constipation management for a resident admitted with bipolar disorder who had bowel incontinence and was dependent on staff for all toileting tasks. The resident’s physician orders included PRN sennoside and polyethylene glycol, along with a bowel routine directing Milk of Magnesia after three days without a bowel movement, bisacodyl suppository after four days, and a fleets enema after five days. The bowel record showed no bowel movement from 4/17/26 through 4/21/26, but the MAR showed no indication that constipation medications were given or that the bowel routine was followed during that period. Staff stated the resident had daily bowel movements, that the resident did not refuse medications, and that constipation medications had not been administered since admission; the DNS stated nursing staff were expected to administer the ordered constipation medications and follow the bowel routine after the specified number of days without a bowel movement. The facility also failed to follow wound care orders for a resident with a BIMS score of 1 and diagnoses including acute cystitis. One elbow wound order indicated no dressing was required, while another elbow wound order directed staff to clean the wound, dry it, and apply a new dressing. During repeated observations, the resident was seen in a wheelchair with the left elbow wound covered by a dressing dated several days earlier and the right elbow dressing peeled off with the wound exposed. The resident was also observed resting arms on wheelchair side rails and bumping an elbow on hallway rails. Staff acknowledged the left elbow dressing was dated earlier than expected, stated the left elbow did not require a dressing, and later removed the right elbow dressing and applied a new one. The resident care manager stated staff were expected to follow wound care orders and that she was unaware the wound care orders had not been completed.
Failure to Provide and Monitor AFO Use for Mobility Support
Penalty
Summary
The facility failed to provide treatment, services, equipment, and assistance to maintain or improve mobility related to the use of a brace for one resident with diagnoses including abnormalities of gait and mobility. The resident’s record showed a BIMS score of 4, use of a walker and wheelchair, and a referral for an AFO due to ankle weakness and instability with a lifetime need. The referral also noted the current AFO did not fit properly, and a care conference later indicated the AFO fit properly only when black shoes were worn. The resident’s care plan and restorative services documentation indicated the resident was to use the right AFO for repeated toilet transfers and staff were to apply the brace daily. During observations over several days, the resident was repeatedly seen sitting in a wheelchair with the right foot inverted to the left side and was not wearing the recommended shoes needed for the brace to fit properly. The resident stated the brace caused increased pain, that staff had adjusted it in the past but it remained painful, and that the resident had never been reassessed for proper fit. Staff gave inconsistent accounts: one CNA stated the resident stopped using the brace months earlier because it was painful and that transfer programs were not offered during the day, another CNA stated the resident was required to use the brace daily and staff knew it was tight and painful, and an LPN stated the brace was not offered and refusals were not documented. The DNS stated the brace had been adjusted but not replaced and that the AFO had not been assessed for comfort or proper fitting since the adjustment.
Failure to Keep Call Light Within Reach for High Fall Risk Resident
Penalty
Summary
The facility failed to implement care plan interventions to prevent falls for one resident who was admitted with diagnoses including a stroke and femur fracture and whose admission MDS indicated cognitive impairment. The resident’s care plan identified the resident as a high fall risk and required one-person assist with transfers and that the call light be kept within reach. A fall assessment documented two unwitnessed falls related to the resident’s attempts to self-transfer to the bathroom independently. During multiple observations, the resident was seen sitting in a wheelchair near the foot of the bed with the call light draped over the head of the bed and out of reach. Staff stated the resident could use the call light appropriately if able to see it, that the resident was forgetful at times, and that the visual of the call light was often used as a reminder to call for assistance. An LPN acknowledged the resident was a high fall risk and stated it was not safe for the resident to ambulate in a wheelchair around the bed to reach the call light.
Improper Suprapubic Catheter Care
Penalty
Summary
The facility failed to properly clean a suprapubic catheter for one sampled resident who was admitted with acute cystitis and had a BIMS score of 1, indicating the resident was not cognitively intact. The resident had orders for daily suprapubic catheter care that specified cleaning the site with warm soapy water or another gentle cleanser, patting it dry, and applying gauze. During observation, staff performed catheter care but cleaned the site with warm water only and did not use soapy water or a cleanser. The staff member acknowledged that she did not use soapy water or a cleanser and stated she forgot. A LPN Resident Care Manager later stated staff were to follow the orders related to the suprapubic catheter.
Failure to Use PPE During Wound and Catheter Care
Penalty
Summary
The facility failed to ensure PPE was used during wound care and catheter care for one sampled resident with diagnoses including acute cystitis and a BIMS score of 1, indicating the resident was not cognitively intact. The resident had orders for daily care of a left elbow wound, a suprapubic catheter site, and a right elbow wound. The 2/2024 CDC guidance cited in the report stated enhanced barrier precautions were required during high-contact activities including device care or wound care. On 4/22/26, Staff 19 emptied another resident’s suprapubic catheter bag without using PPE and stated she was unaware the resident was on enhanced barrier precautions. On 4/23/26, Staff 13 removed the resident’s left elbow dressing in the hallway without PPE, then returned to the room and removed the right elbow dressing and applied a new dressing without PPE. Staff 13 stated PPE was not required because she did not touch the resident’s suprapubic catheter. On 4/24/26, the DNS stated staff were not required to use PPE when changing the resident’s elbow wounds because staff were not in close contact with the suprapubic catheter, and stated PPE was not required when the catheter bag was emptied because the resident did not have a urine infection.
Failure to Provide Complete Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide accurate and complete Notice of Medicare Non-Coverage (NOMNC) forms to two residents, which is a requirement for informing them of their Medicare coverage and potential financial liabilities. Resident 114, who was admitted with diagnoses including diabetes and schizophrenia, had Medicare Part A coverage. The facility sent an incomplete NOMNC form to the resident's Power of Attorney, lacking essential information such as the effective date of coverage, the date when coverage was to end, and contact information for the Quality Improvement Organization for appeal purposes. This form was not signed and returned, and the Social Services Director later acknowledged the form's invalidity due to missing information. Similarly, Resident 115, admitted with dementia and a thoracic vertebrae fracture, also had Medicare Part A coverage. Upon completion of therapy services and clearance for discharge, the facility failed to provide any NOMNC form to this resident. The Social Services Director confirmed that a NOMNC form was necessary but was not provided. These deficiencies indicate a failure in the facility's process to ensure residents are informed of their Medicare coverage details and potential financial responsibilities.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to the care plan for a resident with dementia, who was at risk for falls due to cognitive impairment and required assistance with mobility. The care plan specified the use of a Hoyer lift for transfers and a two-person assistance approach. However, during an incident, a CNA used a Sara lift instead of the Hoyer lift, resulting in the resident's foot slipping and the resident losing balance, which led to a cut on the lower lip and bruising. The CNA admitted to being scared to use the Hoyer sling due to the resident's aggression and acknowledged that the facility was out of Hoyer slings at the time. The CNA attempted to transfer the resident alone using the Sara lift, despite the care plan's requirement for a two-person transfer. The CNA claimed that another staff member was present, but this was contradicted by other staff members who stated they were not in the room during the incident. The facility's administrator confirmed that the CNA did not follow the care plan, which resulted in the resident's fall. The CNA was subsequently terminated as a result of the incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 513 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Linn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rivercrest Post Acute | 3.1 mi | ★★★★★ | 20 | 0 |
| Avamere Rehabilitation Of Oregon City | 3.4 mi | ★★★★★ | 1 | 0 |
| Marquis Oregon City Post Acute Rehab | 3.7 mi | ★★★★★ | 5 | 0 |
| Avamere Rehabilitation Of Clackamas | 4 mi | ★★★★★ | 6 | 0 |
| Fernwood Supportive Living At Madrona Grove | 5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rose Linn Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.