Gracelen Care Center
GRACELEN CARE CENTER in PORTLAND, OR — inspection on October 20, 2025.
Found 2 citations. 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
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.
Facility ID:
38E188
IDENTIFICATION NUMBER:
38E188
A.
Building
COMPLETED
10/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Gracelen Care Center
10948 S.E.
Boise Portland, OR 97266
SUMMARY STATEMENT OF DEFICIENCIES
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] 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] 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.
Facility ID:
38E188
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.