Gracelen Care Center
10948 S.E. Boise · Portland, OR · 97266 · 5037601727
80 certified beds For profit - Corporation
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- 9 citations involved actual harm to residents.
- No federal fines or payment denials in CMS’s 3-year window.
- Inspection results have improved across recent cycles.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 4.37 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.48 | 0.55–0.75 |
| Weekend hours / resident-day | 4.05 | ≈ weekday level |
| Nursing turnover / year | — | median 45% |
| Fines (3-yr window) | none |
Inspection citations (57 in the current record)
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Potential for harm · D March 10, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected April 8, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D October 20, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 25, 2025 · Quality of Life and Care
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Potential for harm · D October 20, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected November 25, 2025 · Quality of Life and Care
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Actual harm · G August 28, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 18, 2025 · Quality of Life and Care
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Potential for harm · D July 25, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected August 26, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 25, 2025
Respond appropriately to all alleged violations.
Corrected August 26, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 25, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected August 26, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 25, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected August 26, 2025 · Quality of Life and Care
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Potential for harm · F July 25, 2025
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.
Corrected August 26, 2025 · Nursing and Physician Services
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Potential for harm · D July 25, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected August 26, 2025 · Pharmacy Service
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Potential for harm · D July 25, 2025
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected August 26, 2025 · Pharmacy Service
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Potential for harm · D July 25, 2025
Provide and implement an infection prevention and control program.
Corrected August 26, 2025 · Infection Control
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Potential for harm · D December 19, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 19, 2024 · found via complaint
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected January 28, 2025 · Resident Rights
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Potential for harm · D April 8, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected May 14, 2024 · Resident Rights
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Potential for harm · D April 8, 2024
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected May 14, 2024 · Resident Rights
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Potential for harm · D April 8, 2024
Reasonably accommodate the needs and preferences of each resident.
Corrected May 14, 2024 · Resident Rights
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Potential for harm · D April 8, 2024
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected May 14, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D April 8, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected May 14, 2024 · Resident Assessment and Care Planning
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Potential for harm · D April 8, 2024
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected May 14, 2024 · Resident Assessment and Care Planning
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Potential for harm · D April 8, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected May 14, 2024 · Quality of Life and Care
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Potential for harm · E April 8, 2024
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected May 14, 2024 · Nursing and Physician Services
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Potential for harm · E April 8, 2024
Observe each nurse aide's job performance and give regular training.
Corrected May 14, 2024 · Nursing and Physician Services
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Potential for harm · D April 8, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected May 14, 2024 · Pharmacy Service
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Potential for harm · F April 8, 2024
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.
Corrected May 14, 2024 · Nutrition and Dietary
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 38E188 · certified since December 6, 1976. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.