Gracelen Care Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
would contact the on-call provider for further direction.On 10/17/25 at 1:20 PM Staff 41 (NP) stated they rounded on Resident 7, who was normally alert, and they would expect an immediate call if there were a change in the resident's mentation such as not able to be aroused or the inability to follow direction and take medications. Staff 41 stated they expected an assessment by the licensed nurse and blood sugar levels checked.On 10/20/25 at 9:27 AM Staff 42 (NP) stated they were on-call on 12/8/24 and did not receive a notification of Resident 7's change of change in mental status.On 10/20/25 Staff 4 (LPN Resident Care Manager) stated they expected the nurse to assess the resident, obtain a set of vital signs, and based
on findings contact the on-call provider when a change of condition was reported to them. Staff 4 reviewed Resident 7's medical record and acknowledged there was no documentation by Staff 43 of an assessment, vital signs, blood sugar checks or communication with the on-call provider on 12/8/24. On 10/20/25 Staff 2 (DNS) stated if staff expressed concerns to the charge nurse about a resident's change of condition, such as signs of altered mental status, they expected the nurse to perform a full assessment, take vital signs, if appropriate check blood sugar levels, and contact the on-call provider. Staff 2 acknowledged there was no documentation to indicate an assessment was performed, vital signs taken, blood sugar levels were checked, or the on-call provider was notified for Resident 7 on 12/8/24 by Staff 43 after they were notified of
the resident's change of condition.
Event ID:
Facility ID:
38E188
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
38E188
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/20/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Gracelen Care Center
10948 S.E. Boise Portland, OR 97266
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0686
F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
were responsible for verifying and entering the orders into the resident's record. On 10/20/25 at 10:30 AM Staff 4 (LPN Resident Care Manager) stated they expected the admitting nurse to thoroughly assess and photograph all wounds within the first eight hours of admission and make a referral to the wound clinic. Staff 4 stated they expected wound care orders to be implemented the same day as receipt. Staff 4 acknowledged no assessment of Resident 7's wound was performed upon admission on [DATE REDACTED] and there was no documentation in the TAR or progress notes of wound care treatment provided between 11/13/24 and 11/19/24. Staff 4 acknowledged Resident 7 was readmitted to the facility on [DATE REDACTED] with treatment orders for wounds to the sacrum and both heels. Staff 4 acknowledged treatment for the sacral wound was not initiated until 11/28/24, treatment for the left heel was not initiated until 12/6/24 and there was no record of treatment provided for the right heel.
Event ID:
Facility ID:
38E188
If continuation sheet
GRACELEN CARE CENTER in PORTLAND, OR inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PORTLAND, OR, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GRACELEN CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.