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Nursing HomeMedicaid Investigative

Gracelen Care Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

10948 S.e. Boise, Southeast Portland · Portland, OR 9726680 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
2.5/5

based on 17 Google reviews

5
4
3
2
1
Gracelen Care Center Nursing Home in Portland, OR — Street View
Street View

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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Above-median deficiencies (11 vs median 9.0)

Bottom 25% in OR · Below recommended RN staffing · Above recommended total nurse staffing · No penalties on record

Source: Medicare data

What this means for your family

We strongly advise against considering this facility based on the consistent and severe reports of neglect, overcrowding, and poor medical oversight. If you are currently evaluating options, please prioritize facilities with transparent staffing ratios and positive recent inspections, as the current feedback for this location indicates a high risk to resident safety.

Google Reviews

Google Reviews

17 reviews on Google
Gracelen Care Center faces severe and consistent criticism regarding patient neglect, lack of privacy, and poor living conditions. Multiple reviewers report that residents are housed four to a room, experience significant delays in assistance, and suffer from inadequate hygiene and medical care. While some older reviews from 2017-2018 praised the memory care staff, the overwhelming majority of recent feedback describes a facility in crisis.

Quality Themes

Tap a score for details
Food1.0Staff1.0Clean1.0ActivitiesN/AMeds1.0Memory4.0Comms1.0ValueN/A

Strengths

  • Historical praise for memory care staff
  • Quiet, pleasant grounds (historical)

Concerns

  • Severe overcrowding with 4 residents per room (mentioned by 4 reviewers)
  • Neglect of basic hygiene and medical needs (mentioned by 5 reviewers)
  • Slow or non-existent staff response to calls for help (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

2341.0'14(1)4.05.0'17(2)5.01.0'23(3)1.02.2'25(5)1.0'26(2)

Distribution · 19 analyzed

5
5
4
1
3
1
2
0
1
12

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Given that some rooms accommodate four residents, how do you ensure each individual receives adequate personal space and privacy?
  • 2Could you walk me through your current process for responding to call lights and how you ensure residents receive timely assistance?
  • 3With the recent focus on improving cleanliness and hygiene standards, what specific daily protocols are now in place to maintain the living areas?
  • 4How does your team coordinate medication management to ensure accuracy and consistency for residents with complex health needs?
  • 5What steps are you taking to improve communication with families regarding changes in a resident's health or daily well-being?
  • 6Can you describe how your staff is currently trained to support the specific needs of memory care residents to ensure they feel engaged and safe?

Personalized based on this facility's data


Key Review Excerpts

Most residents will be left to sit in their own urine for the most of the day and only changed a few times, if that.

Long-term resident's family · 2025☆☆☆☆

My father was on hospice and its all I can do to flag people down to get him meds to make him feel ok. They cram people in 4 people to a room.

Long-term resident's family · 2025☆☆☆☆

They caused my father to have bed sores and then blamed him for the injury. The food is terrible, and they don't give enough portions to feed everyone.

Long-term resident's family · 2023☆☆☆☆
Source: 17 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.48hrs
64%
Registered nurses for medical care
Total Nursing
4.37hrs
OK
All nurses + aides combined

RN hours are below the national benchmark. RNs handle complex medical needs and medication, so ask about coverage during your visit.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 16 measures

Medicare Rating
4/ 5
Better Than Avg

7

measures

Worse Than Avg

4

measures

Mixed Results

5

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility27.0%
Worse than Avg
Here
27.0%
US
15.4%
OR
14.0%
Multnomah
13.8%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility12.6%
Mixed vs Avgs
Here
12.6%
US
19.5%
OR
12.5%
Multnomah
11.9%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility99.6%
Better than Avg
Here
99.6%
US
93.4%
OR
95.3%
Multnomah
94.5%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility20.3%
Worse than Avg
Here
20.3%
US
14.4%
OR
15.3%
Multnomah
15.8%
😔

Residents with depression symptoms

↓ Lower is better
This Facility6.4%
Mixed vs Avgs
Here
6.4%
US
12.1%
OR
4.9%
Multnomah
4.4%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚶

Residents whose walking got worse

↓ Lower is better
This Facility17.7%
Mixed vs Avgs
Here
17.7%
US
15.3%
OR
22.5%
Multnomah
21.7%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility98.3%
Better than Avg
Here
98.3%
US
81.8%
OR
85.5%
Multnomah
84.1%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility85.3%
Better than Avg
Here
85.3%
US
79.7%
OR
81.2%
Multnomah
81.0%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

12deficiencies
Above state avg (10.4)
18 complaint-triggered

Gracelen Care Center has faced recurring problems with families filing multiple complaints about safety hazards, abuse prevention, and quality of care. The facility shows persistent issues across medication management, infection control, and resident safety that have continued across recent surveys through 2025. While the provider reports correcting deficiencies, the pattern of repeated violations in core care areas suggests ongoing operational challenges families should carefully consider.

Mar 10, 2026Complaint
1
0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Oct 20, 2025Complaint
2
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Aug 28, 2025Complaint
1
0689Actual harm · IsolatedResolved (past non-compliance)

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Jul 25, 2025Routine
10
0727Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

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.

0200Potential for harm · WidespreadCorrected

Egress Deficiencies

Meet other general requirements.

0500Potential for harm · WidespreadCorrected

Services Deficiencies

Meet other general requirements that are deficient.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0761Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

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.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Dec 19, 2024Complaint
2
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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

0622Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

Apr 8, 2024Routine
16
0801Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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.

0039Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0353Potential for harm · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0726Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

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.

0730Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0947Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

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

0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0552Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0604Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0661Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

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

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Gracelen Care Center

Organization Type

for profit

Ownership & Management

Owners

Undisclosed

Ownership Data Not Available · Organization

Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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