Stanley Post Acute: Fall from Care Plan Failure - OR
The resident, identified in federal inspection records as Resident 7, had been at the facility since September 2015. The diagnoses on file included multiple sclerosis and overactive bladder. The care plan, updated in September 2024, was explicit: two people were required to assist with toileting. The reasoning behind that requirement isn't complicated. A person with multiple sclerosis who needs help with toilet hygiene and needs two staff members to do it safely is not a person who can be repositioned by one aide working alone.
The agency CNA, identified in records as Staff 5, made a different calculation. She rolled the resident off the bed while providing toileting care without a second person present. Resident 7 fell.
That was February 4, 2025. The facility opened an investigation.
Six months later, a federal inspector came to Stanley Post Acute on a complaint inspection. On August 25, 2025, Resident 7 described what had happened in their own words: the staff member rolled them off the bed because the CNA said she could provide the care herself and did not need another person to assist.
Resident 7 is cognitively intact. A quarterly assessment completed in May 2025 gave the resident a score of 15 on the Brief Interview for Mental Status, the highest possible score, meaning full cognitive function. This is not a resident whose account of events is in question.
Three days after that interview, on August 28, the facility's administrator and director of nursing sat down with the inspector. Both acknowledged that Resident 7's care plan was not followed when the fall occurred.
That acknowledgment is the end of what the inspection report documents. It doesn't say what happened to the agency CNA. It doesn't say whether the staffing agency was notified, whether the contract was reviewed, or whether Staff 5 ever returned to the floor. It doesn't say how Resident 7 was injured or how seriously, noting only that the harm level was classified as minimal harm or potential for actual harm, the lowest tier in the federal deficiency system.
What it does say is that a written plan existed, a fall happened because that plan was ignored, and the people running the facility confirmed both facts to a federal inspector more than six months after the incident.
The use of agency staff, sometimes called contract or travel CNAs, in nursing homes has grown substantially in recent years, driven by chronic workforce shortages across the industry. Agency workers are often unfamiliar with individual residents, their histories, their care plans, and the specific physical requirements that distinguish one resident's needs from another's. A two-person assist requirement for toileting isn't a bureaucratic formality. It reflects something real about what a particular body can and cannot do safely.
Resident 7's care plan existed because someone assessed that resident and determined that one person was not enough. The CNA who showed up that night in February reached a different conclusion. She was wrong, and the resident paid for it.
The inspection covered one resident for this deficiency. The report does not indicate whether other residents at Stanley Post Acute had similar care plan requirements that went unverified or unenforceable with agency staff on the floor.
Resident 7 has lived at Stanley Post Acute for nearly ten years. The fall happened in February. The inspector's interview with the resident happened in August. Somewhere in those six months, the resident kept living there, dependent on staff for toileting, with a care plan that had already been ignored once.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stanley Post Acute from 2025-08-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
STANLEY POST ACUTE in MILWAUKIE, OR was cited for violations during a health inspection on August 28, 2025.
The resident, identified in federal inspection records as Resident 7, had been at the facility since September 2015.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.