Gracelen Care Center

• Star rating

  The CMS overall star rating changed from 1 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 5 of 5.

CMS lists this as a complaint inspection.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on June 2, 2026.

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CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on April 8, 2026.

  CMS has cited this home for F0609 3 times since 2024.

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• CMS abuse icon

  CMS removed its abuse icon from this home.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• CMS abuse icon

  CMS added its abuse icon to this home.

• Health citation

  CMS changed citation F0600 from severity E to D. It is from the health inspection on April 8, 2024. Severity D: potential for more than minimal harm, isolated.

CMS lists this as a complaint inspection.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on November 25, 2025.

  CMS has cited this home for F0684 3 times since 2023.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on November 25, 2025.

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• Star rating

  The CMS staffing star rating changed from 1 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

23 of 128 Oregon homes (18%) got a citation at the actual harm level in 2025.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on August 18, 2025.

  CMS has cited this home for F0689 3 times since 2023.

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• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

CMS lists this as a standard inspection.

• Citation F0727. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 26, 2025.

  CMS has cited this home for F0727 2 times since 2023.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on August 26, 2025.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on August 26, 2025.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on August 26, 2025.

  CMS has cited this home for F0656 2 times since 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on August 26, 2025.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on August 26, 2025.

  CMS has cited this home for F0759 2 times since 2023.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on August 26, 2025.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on August 26, 2025.

  CMS has cited this home for F0880 3 times since 2023.

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CMS lists this as a standard inspection.

• Citation K0200. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Meet other general requirements.

  CMS lists it as corrected on August 26, 2025.

• Citation K0500. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Meet other general requirements that are deficient.

  CMS lists it as corrected on August 26, 2025.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.

• Staffing

  Total nurse staffing reported to CMS went from 4.8 to 4.2 hours per resident per day.

CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on January 28, 2025.

  CMS has cited this home for F0600 2 times since 2024.

• Citation F0622. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on January 28, 2025.

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• Star rating

  The CMS staffing star rating changed from 1 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0801. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 14, 2024.

  CMS has cited this home for F0801 2 times since 2023.

• Citation F0726. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 14, 2024.

• Citation F0730. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Observe each nurse aide's job performance and give regular training.

  CMS lists it as corrected on May 14, 2024.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on May 14, 2024.

• Citation F0947. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

  CMS lists it as corrected on May 14, 2024.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on May 14, 2024.

  CMS has cited this home for F0550 2 times since 2023.

• Citation F0552. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS lists it as corrected on May 14, 2024.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on May 14, 2024.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 14, 2024.

  CMS has cited this home for F0584 2 times since 2023.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on July 2, 2024.

• Citation F0604. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  CMS lists it as corrected on May 14, 2024.

  CMS has cited this home for F0604 2 times since 2023.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on May 14, 2024.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on May 14, 2024.

  CMS has cited this home for F0657 2 times since 2023.

• Citation F0661. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

  CMS lists it as corrected on May 14, 2024.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on May 14, 2024.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on May 14, 2024.

  CMS has cited this home for F0757 2 times since 2023.

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CMS lists this as a standard inspection.

• Citation E0039. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on May 14, 2024.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on May 14, 2024.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on May 14, 2024.

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• Name

  CMS lists a new name for this home. It was GRACELEN TERRACE NF.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

CMS lists this as a standard inspection.

Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

13 of 128 Oregon homes (10%) got a citation at the immediate jeopardy level in 2023.

• Citation F0880. Severity K: immediate jeopardy, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on March 10, 2023.

• Citation F0867. Severity H: actual harm, pattern.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on March 10, 2023.

• Citation F0684. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on March 10, 2023.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on March 10, 2023.

• Citation F0825. Severity G: actual harm, isolated.

  The rule CMS cited: Provide or get specialized rehabilitative services as required for a resident.

  CMS lists it as corrected on March 10, 2023.

• Citation F0801. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on March 10, 2023.

• Citation F0882. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

  CMS lists it as corrected on March 10, 2023.

• Citation F0727. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on March 10, 2023.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on March 10, 2023.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on March 10, 2023.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on March 10, 2023.

• Citation F0604. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

  CMS lists it as corrected on March 10, 2023.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on March 10, 2023.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on March 10, 2023.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on March 10, 2023.

• Citation F0679. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on March 10, 2023.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on March 10, 2023.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on March 10, 2023.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on March 10, 2023.

• Citation F0883. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures for flu and pneumonia vaccinations.

  CMS lists it as corrected on March 10, 2023.

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CMS lists this as a standard inspection.

• Citation K0222. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on March 10, 2023.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on March 10, 2023.

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