Stanley Post Acute
12045 SE Stanley Avenue, Milwaukie, OR 97222 · Clackamas County · 96 certified beds · avg 88 residents/day · certified since Oct 18, 2005
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
3/5
Health inspection rating (on-site)
1
Serious findings on record
$8,278
Fines, last 3 years
4.86
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 20, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 23, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (32)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 20, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 5, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Sep 5, 2025 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Sep 5, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Sep 5, 2025 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Sep 5, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Sep 5, 2025 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 14, 2025 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. · from a complaint |
| Feb 14, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 20, 2024 | E · Potential for harm, repeated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. · from a complaint |
| May 20, 2024 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings. · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| May 20, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Mar 27, 2023 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Mar 27, 2023 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Mar 27, 2023 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Mar 27, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 27, 2023 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Mar 27, 2023 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Mar 27, 2023 | D · Potential for harm, one-off | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Mar 27, 2023 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (14 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 8 | 0 | D |
| 2024 | 14 | 0 | E |
| 2025 | 9 | 0 | E |
| 2026 | 1 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $8,278.
| Date | Type | Amount / length |
|---|---|---|
| Feb 20, 2026 | Fine | $8,278 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Oregon avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.86 | 5.42 | 3.95 | bottom 21% in Oregon; top 16% in the U.S. |
| Registered Nurse hours | 0.22 | 0.78 | 0.69 | bottom 1% in Oregon; bottom 3% in the U.S. |
| Weekend total nurse staffing | 4.50 | 4.85 | 3.50 | bottom 30% in Oregon; top 12% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.16 | 0.48 | 0.48 | bottom 3% in Oregon; bottom 7% in the U.S. |
| Total nursing staff turnover (%) | 58.1 | 47.4 | 45.8 | bottom 25% in Oregon; bottom 19% in the U.S. |
| RN turnover (%) | 66.7 | 51.6 | 42.9 | bottom 30% in Oregon; bottom 15% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.65, RN 0.21, weekend 4.31. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Apt, Frederick | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Cano, Pilo | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Cano, Pilo | Individual | ADP of the SNF | NOT APPLICABLE | 07/02/2025 |
| Jergensen, Joshua | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Kempfer, Gretchen | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/16/2024 |
| Milwaukie 12045 Realty LLC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2024 |
| Mitchell, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Morris, Christopher | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Morris, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 07/02/2025 |
| Providence Administrative Consulting Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2024 |
| Truist Bank | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 09/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you explain health changes and treatment options to residents and their families?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How do residents get dental care here — is there a dentist who visits, and how are appointments arranged?"
- "What exactly do you hand off to the next provider when a resident is discharged, and how do you confirm they received it?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Willamette View Health Center | 2.5 mi | Milwaukie, OR | ★★★★★ | 5/5 | |
| Fernwood Supportive Living at Madrona Grove | 2.5 mi | Portland, OR | ★★★★☆ | 3/5 | |
| Avamere Rehabilitation of Clackamas | 3.7 mi | Gladstone, OR | ★★★★☆ | 3/5 | |
| Gracelen Care Center | 3.8 mi | Portland, OR | ★☆☆☆☆ | 1/5 | |
| The Creston Health & Rehabilitation | 4.0 mi | Portland, OR | ★☆☆☆☆ | 1/5 | |
| Secora Rehabilitation of Cascadia | 4.2 mi | Portland, OR | ★★☆☆☆ | 2/5 | |
| Reedwood Post Acute | 4.3 mi | Portland, OR | ★★★★★ | 5/5 | |
| Cascade Terrace Post Acute | 4.3 mi | Portland, OR | ★☆☆☆☆ | 1/5 | SFF |
| Cedar Crossings | 4.8 mi | Portland, OR | ★★★☆☆ | 2/5 | |
| Avalon Care Center - Portland | 5.2 mi | Portland, OR | ★★★☆☆ | 2/5 | abuse |
| Mirabella Portland | 5.4 mi | Portland, OR | ★★★★★ | 5/5 | |
| Mt. Tabor Health & Rehabilitation | 5.5 mi | Portland, OR | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 385270.