Stanley Post Acute

Based on interview and record review it was determined the facility failed to ensure staff followed the care plan related to toileting for 1 of 1 sampled resident (#7) reviewed for accidents.

This placed residents at risk for injuries.

Findings include:Resident 7 was admitted to the facility in 9/2015 with diagnoses including multiple sclerosis and overactive bladder.The 5/15/25 Quarterly MDS revealed Resident 7 had a BIMS score of 15, which indicated the resident was cognitively intact, and dependent for toilet hygiene.A review of the 9/14/24 Care Plan revealed Resident 7 required two-person assistance for toileting.A 2/4/25 facility investigation revealed Resident 7 fell out of bed when Staff 5 (Agency CNA) was providing toileting care and did not have a second person assisting.On 8/25/25 at 12:12 PM Resident 7 stated the staff member 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.On 8/28/25 at 1:16 PM Staff 1 (Administrator) and Staff 2 (DNS) acknowledged Resident 7's care was not followed when the fall occurred.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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