Stanley Post Acute: Patient Falls During Unsafe Care - OR
The incident at Stanley Post Acute involved a resident who had lived at the facility since September 2015. The patient, identified as Resident 7 in inspection documents, has multiple sclerosis and an overactive bladder condition that requires careful handling during personal care.
Federal inspectors found that facility staff failed to follow established care plans designed to prevent exactly this type of accident.
The resident's care plan, updated as recently as September 2024, specifically required two-person assistance for all toileting activities. This wasn't a suggestion or guideline. It was a documented requirement based on the patient's medical conditions and physical limitations.
Staff 5, an agency certified nursing assistant, ignored this protocol entirely.
During a February facility investigation, administrators discovered that the CNA had attempted to provide toileting care without requesting backup assistance. The resident fell out of bed during this improper care attempt.
The patient told inspectors exactly what happened during the incident. On August 25, the resident recalled that the agency CNA "rolled her/him off the bed while providing care because the CNA stated she could provide the care herself and did not need another person to assist."
This wasn't a case of miscommunication or unclear instructions. The nursing assistant made a deliberate decision to work alone despite knowing the facility's requirements.
Medical assessments showed the resident remained cognitively intact throughout this period. A May 2025 quarterly assessment revealed a BIMS score of 15, indicating the patient understood what was happening and could accurately report the incident details.
The resident was completely dependent on staff for toilet hygiene, according to the same assessment. This dependency, combined with multiple sclerosis symptoms, made the two-person assistance requirement a critical safety measure.
Agency staff often work at multiple facilities and may not be familiar with individual resident care plans. However, this doesn't excuse the failure to follow documented protocols or the decision to proceed with care that required additional assistance.
The facility's own investigation, completed in February, confirmed that proper procedures weren't followed. Administrators acknowledged the protocol violation months before federal inspectors arrived to review the case.
When federal inspectors interviewed facility leadership on August 28, both the administrator and director of nursing services admitted the care plan wasn't followed during the fall incident.
Staff 1, identified as the facility administrator, and Staff 2, the director of nursing services, acknowledged that "Resident 7's care was not followed when the fall occurred."
This admission came six months after the facility's internal investigation had already documented the same conclusion.
The inspection classified this violation as causing "minimal harm or potential for actual harm" to residents. However, the incident demonstrates how quickly safety protocols can break down when individual staff members decide to take shortcuts.
Multiple sclerosis affects muscle control, balance, and coordination. Patients with this condition face elevated risks during transfers and personal care activities. The two-person assistance requirement existed specifically to prevent falls and injuries during vulnerable moments.
The resident's overactive bladder condition likely meant frequent toileting needs, creating multiple daily opportunities for similar incidents if proper protocols weren't consistently followed.
Federal inspectors found that this case placed residents at risk for injuries, even though the specific harm was classified as minimal. The violation indicates broader concerns about whether staff consistently follow individualized care plans designed to prevent accidents.
Agency nursing assistants work throughout the facility system, often filling gaps in regular staffing. Their unfamiliarity with specific resident needs makes adherence to documented care plans even more critical for preventing accidents and injuries.
The facility failed to ensure that temporary staff understood and followed safety protocols for residents requiring specialized assistance. This failure created the conditions that led directly to the resident's fall from bed during what should have been routine personal care.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
STANLEY POST ACUTE in MILWAUKIE, OR was cited for violations during a health inspection on August 28, 2025.
The incident at Stanley Post Acute involved a resident who had lived 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.