Gracelen Care Center
GRACELEN CARE CENTER in PORTLAND, OR — inspection on August 28, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
resident was sent to the hospital and had surgery for a hip fracture. On 8/28/25 at 11:09 AM Staff 4 (Maintenance Director) stated the shower gurney used in Resident 1's 1/11/25 fall was a new piece of equipment and was different from the other shower chairs used in the facility. He stated he inspected the shower gurney after the incident and observed the medal pin was not locked in the pin bar which was necessary for safety.
Staff 4 immediately removed the shower gurney from the facility, education was provided, and he was unaware of any other falls from equipment in disrepair or misused.
Observations were made of the facility's shower chairs and gurneys on 8/28/25 at 11:14 AM with Staff 4.
Staff 4 demonstrated the shower equipment movements and how to place them in locked position. No shower equipment was found in disrepair. On 8/28/25 at 11:40 AM Staff 2 (DNS) confirmed Resident 1's 1/11/25 fall in the shower resulted in hospitalization and hip surgery.
Staff 2 confirmed she completed the 1/17/25 investigation which concluded the fall was due to staff not properly securing the shower gurney.
She expected all staff to use the shower equipment properly and all parts should be locked while providing a shower. On 1/17/25, the Past Noncompliance was corrected when the facility completed a root cause analysis of the incident and determined staff was not trained for the proper use of the new shower gurney.
The Plan of Correction included: 1.
Staff educated on shower equipment use. 2.
The new shower gurney was removed from the facility until staff were trained and competency was demonstrated. 3.
The Maintenance Director inspected all the shower equipment to ensure safety. 4. If new shower equipment was purchased, which was different than current shower equipment used, the Maintenance Director would conduct training prior to the use of the new equipment. 5.
The Maintenance Director conducts monthly inspection of all shower equipment.
The facility's implementation of corrective actions was verified through the survey process.
Observations conducted throughout the facility on 8/28/25 revealed no concerns with use of shower equipment.
Facility ID:
38E188