Gracelen Care Center
For profit - Corporation · 10948 S.E. Boise, Portland, OR 97266 · See home’s Medicare page
Special Focus Facility Candidate
Has a history of serious quality issues but has not been formally flagged by the government.
No Ownership Data Provided
Home did not provide details about ownership and managerial control of the facility.
4.82
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 4.7
58.2%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 52.9%
80
Certified beds
Qualifying beds in the certified provider or supplier facility.
51
Average residents/day
Average number of residents based on daily census.
Inspection Reports
56
total deficiencies
5
infection-related deficiencies
This home violated federal standards protecting residents from the spread of infections.
Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
Resident Rights Deficiency — F0580
Failure to:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0604
Failure to:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0692
Failure to:
Provide enough food/fluids to maintain a resident's health.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0686
Failure to:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0689
Failure to:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Administration Deficiency — F0777
Failure to:
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0880
Failure to:
Provide and implement an infection prevention and control program.
Severity
Immediate jeopardy to resident health or safety
Scope
Some people affected
Seriousness
Administration Deficiency — F0867
Failure to:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Severity
Actual harm that is not immediate jeopardy
Scope
Some people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0825
Failure to:
Provide or get specialized rehabilitative services as required for a resident.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0689
Failure to:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0801
Failure to:
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Infection Control Deficiency — F0882
Failure to:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Nursing and Physician Services Deficiency — F0727
Failure to:
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0584
Failure to:
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0604
Failure to:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0656
Failure to:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0677
Failure to:
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0679
Failure to:
Provide activities to meet all resident's needs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0690
Failure to:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0757
Failure to:
Ensure each resident's drug regimen must be free from unnecessary drugs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0759
Failure to:
Ensure medication error rates are not 5 percent or greater.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0883
Failure to:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0550
Failure to:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Rights Deficiency — F0580
Failure to:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0657
Failure to:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Resident Assessment and Care Planning Deficiency — F0658
Failure to:
Ensure services provided by the nursing facility meet professional standards of quality.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0689
Failure to:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
Actual harm that is not immediate jeopardy
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0552
Failure to:
Ensure that residents are fully informed and understand their health status, care and treatments.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0602
Failure to:
Protect each resident from the wrongful use of the resident's belongings or money.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0677
Failure to:
Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0689
Failure to:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Administration Deficiency — F0770
Failure to:
Provide timely, quality laboratory services/tests to meet the needs of residents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Infection Control Deficiency — F0886
Failure to:
Perform COVID19 testing on residents and staff.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Many people affected
Seriousness
Resident Rights Deficiency — F0578
Failure to:
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Infection Control Deficiency — F0883
Failure to:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Resident Rights Deficiency — F0550
Failure to:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0688
Failure to:
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0690
Failure to:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nursing and Physician Services Deficiency — F0727
Failure to:
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Administration Deficiency — F0770
Failure to:
Provide timely, quality laboratory services/tests to meet the needs of residents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0684
Failure to:
Provide appropriate treatment and care according to orders, resident's preferences and goals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Quality of Life and Care Deficiency — F0689
Failure to:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Nutrition and Dietary Deficiency — F0805
Failure to:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0607
Failure to:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0609
Failure to:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0610
Failure to:
Respond appropriately to all alleged violations.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0600
Failure to:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0604
Failure to:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Freedom from Abuse, Neglect, and Exploitation Deficiency — F0605
Failure to:
Ensure that each resident is free from medications that restrain them, unless needed for medical treatment.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Pharmacy Service Deficiency — F0758
Failure to:
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
Penalties
$1,625
total fines
A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.