Inspection Reports for
Stanley Post Acute
12045 SE Stanley Avenue, Milwaukie, OR, 97222
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
20.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
203% worse than Oregon average
Oregon average: 6.7 deficiencies/year
Deficiencies per year
28
21
14
7
0
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 2
Date: Nov 4, 2025
Visit Reason
Two initial comment citations were noted with no deficiencies corrected at the time of visit.
Findings
Two initial comment citations were noted with no deficiencies corrected at the time of visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 9
Date: Sep 5, 2025
Visit Reason
Nine citations including issues with resident rights, advance directives, mobility, drug labeling, dental services, infection control, and administrative rules. All deficiencies were corrected by 9/29/2025.
Findings
Nine citations including issues with resident rights, advance directives, mobility, drug labeling, dental services, infection control, and administrative rules. All deficiencies were corrected by 9/29/2025.
Deficiencies (9)
F0000 - INITIAL COMMENTS
F0552 - Right to be Informed/Make Treatment Decisions
F0578 - Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir
F0688 - Increase/Prevent Decrease in ROM/Mobility
F0761 - Label/Store Drugs and Biologicals
F0791 - Routine/Emergency Dental Srvcs in NFs
F0880 - Infection Prevention & Control
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 5, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, medication management, advance directives, restorative services, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to inform a resident about psychotropic medication risks, lack of resident advance directives in medical records, inconsistent provision of restorative range of motion services, improper labeling of medications, failure to assist a resident with obtaining dentures, and inadequate infection prevention practices including improper cleaning of reusable medical equipment and failure to perform hand hygiene.
Deficiencies (6)
F 0552: The facility failed to inform Resident 37 of the risks and benefits of psychotropic medication quetiapine fumarate as required.
F 0578: The facility failed to ensure advance directives were available in the medical records for Residents 46 and 96.
F 0688: The facility failed to consistently provide passive range of motion exercises to Resident 96 as indicated in the care plan.
F 0761: The facility failed to ensure proper labeling of insulin glargine vial, which lacked an open date.
F 0791: The facility failed to assist Resident 3 with obtaining new dentures as ordered and did not follow up after the dental appointment.
F 0880: The facility failed to use appropriate disinfection practices for reusable medical equipment, failed to clean community use glucometer between residents, and staff failed to perform hand hygiene during meal service.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents reviewed for advance directives: 4
Residents reviewed for mobility: 1
Treatment carts reviewed for medication storage: 2
Residents reviewed for dental care: 2
Halls reviewed for infection control and meal service: 4
Residents reviewed during medication pass: 1
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 4
Date: Aug 28, 2025
Visit Reason
Four citations including accident hazards and administrative rules. Deficiencies were corrected by 9/29/2025.
Findings
Four citations including accident hazards and administrative rules. Deficiencies were corrected by 9/29/2025.
Deficiencies (4)
F0000 - INITIAL COMMENTS
F0689 - Free of Accident Hazards/Supervision/Devices
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 2
Date: May 15, 2025
Visit Reason
Two initial comment citations noted with no deficiencies corrected at the time of visit.
Findings
Two initial comment citations noted with no deficiencies corrected at the time of visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 5
Date: Feb 14, 2025
Visit Reason
Five citations including discharge summary, quality of care, and administrative rules. Some deficiencies corrected by 3/3/2025, others remained uncorrected.
Findings
Five citations including discharge summary, quality of care, and administrative rules. Some deficiencies corrected by 3/3/2025, others remained uncorrected.
Deficiencies (5)
F0000 - INITIAL COMMENTS
F0661 - Discharge Summary
F0684 - Quality of Care
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 2
Date: May 21, 2024
Visit Reason
Two initial comment citations noted with no deficiencies corrected at the time of visit.
Findings
Two initial comment citations noted with no deficiencies corrected at the time of visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 17
Date: May 20, 2024
Visit Reason
Seventeen citations covering resident rights, self-administration of meds, dignity, comprehensive assessments, baseline care plans, quality of care, foot care, accident hazards, respiratory care, pain management, nurse aide reviews, mental health treatment, drug labeling, resident records, and administrative rules. Many deficiencies corrected by 6/13/2024, others remained uncorrected.
Findings
Seventeen citations covering resident rights, self-administration of meds, dignity, comprehensive assessments, baseline care plans, quality of care, foot care, accident hazards, respiratory care, pain management, nurse aide reviews, mental health treatment, drug labeling, resident records, and administrative rules. Many deficiencies corrected by 6/13/2024, others remained uncorrected.
Deficiencies (17)
F0000 - INITIAL COMMENTS
F0550 - Resident Rights/Exercise of Rights
F0554 - Resident Self-Admin Meds-Clinically Approp
F0557 - Respect, Dignity/Right to have Prsnl Property
F0636 - Comprehensive Assessments & Timing
F0655 - Baseline Care Plan
F0684 - Quality of Care
F0687 - Foot Care
F0689 - Free of Accident Hazards/Supervision/Devices
F0695 - Respiratory/Tracheostomy Care and Suctioning
F0697 - Pain Management
F0730 - Nurse Aide Peform Review-12 hr/yr In-Service
F0742 - Treatment/Srvcs Mental/Psychoscial Concerns
F0761 - Label/Store Drugs and Biologicals
F0842 - Resident Records - Identifiable Information
M0000 - Initial Comments
M9999 - STATE OF OREGON ADMINISTRATIVE RULES
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 2
Date: Mar 13, 2024
Visit Reason
Two initial comment citations noted with no deficiencies corrected at the time of visit.
Findings
Two initial comment citations noted with no deficiencies corrected at the time of visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Complaint Investigation
Capacity: 96
Deficiencies: 2
Date: Feb 1, 2024
Visit Reason
Two initial comment citations noted with no deficiencies corrected at the time of visit.
Findings
Two initial comment citations noted with no deficiencies corrected at the time of visit.
Deficiencies (2)
F0000 - INITIAL COMMENTS
M0000 - Initial Comments
Inspection Report
Capacity: 96
Deficiencies: 1
Date: Aug 7, 2023
Visit Reason
One citation for failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency was not corrected at time of visit.
Findings
One citation for failure to report complete COVID-19 information to CDC's NHSN during a required seven-day period. Deficiency was not corrected at time of visit.
Deficiencies (1)
F0884 - Reporting - National Health Safety Network
Inspection Report
Routine
Deficiencies: 8
Date: Mar 27, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements for nursing home care and services.
Findings
The facility was found deficient in multiple areas including failure to provide residents the opportunity to formulate advance directives, failure to conduct significant change assessments, incomplete PASRR Level II screenings, inadequate care planning for anticoagulant medication monitoring, failure to provide necessary behavioral health services, medication administration errors, lack of qualified dietary staff, and improper food storage and handling practices.
Deficiencies (8)
F 0578: The facility failed to ensure residents were provided the opportunity to formulate advance directives for 1 sampled resident, placing residents at risk for uninformed health care decisions.
F 0637: The facility failed to document and conduct a Significant Change MDS assessment for 1 sampled resident after a major decline in condition, risking unassessed care needs.
F 0645: The facility failed to ensure a PASRR Level II screening was completed for 1 sampled resident, risking lack of specialized services.
F 0656: The facility failed to develop and implement a care plan that included monitoring for bruising or bleeding related to anticoagulant medication for 1 sampled resident.
F 0740: The facility failed to provide necessary behavioral health care and services for 1 sampled resident, resulting in unmet behavioral and emotional needs.
F 0760: The facility failed to ensure residents were free from significant medication errors for 1 sampled resident, including incorrect administration times and missed doses.
F 0801: The facility failed to employ a director of food and nutrition services with the required certification for 1 facility reviewed for qualified dietary staff.
F 0812: The facility failed to prepare and store foods properly, including leaving uncovered food items and curdled milk at room temperature, risking foodborne illness.
Report Facts
Medication administration errors: 5
Dates of medication administration errors: Feb 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff 4 | Social Services Director | Named in findings related to advance directives, PASRR screening, and behavioral health care deficiencies |
| Staff 3 | LPN | Confirmed anticoagulant medication risks and care plan deficiencies for Resident 8 |
| Staff 5 | CNA | Provided information on Resident 38's condition change and care needs |
| Staff 6 | LPN | Acknowledged significant change assessment should have been completed and reviewed PHQ-9 scores |
| Staff 7 | Food Service Manager | Functioned as director of food and nutrition services without required certification; reported on food safety issues |
| Staff 2 | DNS (Director of Nursing Services) | Verified medication administration errors and commented on food safety practices |
| Staff 9 | LPN | Discussed food safety issue with Resident 31 and milk spoilage |
| Staff 8 | Regional RN | Provided documentation on behavioral health provider visits for Resident 12 |
Inspection Report
Deficiencies: 1
Date: Mar 27, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and sanitary practices in the kitchen and food service areas.
Findings
The facility failed to properly prepare and store foods, including leaving uncovered food items in the kitchen and allowing curdled milk to remain in a resident's room, placing residents at risk of foodborne illness.
Deficiencies (1)
F0812: The facility failed to procure food from approved sources and store, prepare, distribute, and serve food according to professional standards. Milk was found curdled and left at room temperature in a resident's room, and open food items were left uncovered on the kitchen prep island.
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