01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-09-05 | 8 | 2025-09-05 | 2 |
| Cycle 2 | 2024-05-20 | 16 | 2024-05-20 | 2 |
| Cycle 3 | 2023-03-27 | 8 | 2023-03-27 | 1 |
CMS CCN 3852702026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Stanley Post Acute
12045 Se Stanley Avenue · Milwaukie, OR 97222 · Clackamas County
Certified beds96CMS provider file
Recent citation rows37current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
37 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-02-20 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-02-23 · complaint2025-09-05 · FIREE0013Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-09-05 · FIREE0020Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures including evacuation.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-09-05 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-09-05 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-09-05 · HEALTHF0688Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-09-05 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-09-05 · HEALTHF0791Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-09-05 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-152025-08-28 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-10-15 · complaint2025-02-14 · HEALTHF0661Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-03-12 · complaint2025-02-14 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-03-12 · complaint2024-05-20 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Past Non-Compliance · 2024-03-03 · complaint2024-05-20 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2024-06-25 · complaint2024-05-20 · HEALTHF0557Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Correction field: Deficient, Provider has date of correction · 2024-06-25 · complaint2024-05-20 · HEALTHF0636Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Correction field: Deficient, Provider has date of correction · 2024-06-25 · complaint2024-05-20 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2024-06-25 · complaint2024-05-20 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-06-25 · complaint2024-05-20 · HEALTHF0687Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate foot care.
Correction field: Deficient, Provider has date of correction · 2024-06-25 · complaint2024-05-20 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-06-25 · complaint2024-05-20 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-06-25 · complaint2024-05-20 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-06-25 · complaint2024-05-20 · HEALTHF0730Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2024-06-25 · complaint2024-05-20 · HEALTHF0742Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Correction field: Deficient, Provider has date of correction · 2024-06-25 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2026-02-20 | Fine | $8,278 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- TRUIST BANKOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 09/01/2024
- APT, FREDERICKIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/10/2024
- CANO, PILOIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- JERGENSEN, JOSHUAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/10/2024
- KEMPFER, GRETCHENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/16/2024
- MITCHELL, JOHNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 05/10/2024
- MORRIS, CHRISTOPHERIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- MILWAUKIE 12045 REALTY LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 09/01/2024
- PROVIDENCE ADMINISTRATIVE CONSULTING SERVICES INCOrganization · ADP OF THE SNFNOT APPLICABLE · since 09/01/2024
- CANO, PILOIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/02/2025
- MORRIS, CHRISTOPHERIndividual · ADP OF THE SNFNOT APPLICABLE · since 07/02/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.65per resident day
RN hours0.21per resident day
Weekend nurse hours4.31per resident day
Staff turnover58.1%CMS reported field
06 / LOCAL RECORDS
Open the Milwaukie ledger →