Green Lea Senior Living: Brain Bleed Unreported - MN
The resident, identified in inspection records only as Resident 1, had been diagnosed with hemiplegia and hemiparesis following a cerebral infarction — conditions that left her with paralysis and partial weakness on one side of her body. She fell on September 26, September 28, September 30, and October 1. After none of those falls did the facility complete a comprehensive analysis of what was causing them, and after none of them did staff put in place any documented interventions to reduce the risk of another.
The fifth fall happened on the morning of October 3.
An incident report filed at 9:24 a.m. that day described her as restless, with gait imbalance and weakness. She was sent to the emergency department by ambulance. That afternoon, at 2:57 p.m., a licensed practical nurse called the hospital to check on her and was told she was being kept for observation for a brain bleed. By that evening, a progress note confirmed she had been admitted.
The licensed practical nurse, identified in the inspection report as LPN-A, told the assistant director of nursing about the brain bleed. Then she stopped there. She assumed the assistant director of nursing had passed the information to the administrator. She also told inspectors she believed the reporting deadline was two hours to the administrator, and that she had no idea the facility was also required to report serious injuries to the state agency within that same window.
Nobody reported it to the state. Not that day. Not the next day. Not at all, until inspectors arrived on October 14.
The administrator, interviewed that afternoon, confirmed it. The fall with serious injury had not been reported to the state agency when the facility learned about the brain bleed, she said, and it should have been reported within two hours. She told inspectors she did not know why it hadn't been.
The director of nursing offered one explanation: she had been on vacation when it happened, and the assistant director of nursing was running the building. But the director of nursing was clear that the brain bleed following a fall required a report to the state within two hours of the facility learning about it, and that no such report had been made.
The assistant director of nursing, who was the person LPN-A actually told about the brain bleed, does not appear to have contacted anyone outside the facility.
What makes the lapse harder to explain is that the facility had a written policy covering exactly this situation. The abuse investigation and reporting policy, dated April 17, 2025 — less than six months before the fall — stated that any alleged violation involving abuse or serious bodily injury had to be reported within two hours to local, state, and federal agencies. A brain bleed is a serious bodily injury. The policy was current. The obligation was written down.
It did not get followed.
The inspection report describes a chain of assumptions, each one passing the responsibility to the next person, until nobody was left. LPN-A assumed the assistant director of nursing had told the administrator. The assistant director of nursing, apparently, did not escalate to the state. The administrator did not know why. The director of nursing was on vacation and learned about it later. The result was a resident with a brain bleed, admitted to a hospital, and a state agency that went uninformed.
The failure to report was cited under federal tag F0609, which governs timely reporting of suspected abuse, neglect, or theft, and the results of investigations, to proper authorities. Inspectors rated the level of harm as minimal harm or potential for actual harm.
What the inspection record does not contain is any documentation that the facility, in the days between October 3 and October 14, attempted to file a late report or notified the state in any form. The administrator's statement to inspectors suggested the omission was discovered during the survey itself.
The inspection also noted that after each of the first four falls — September 26, September 28, September 30, and October 1 — there was no comprehensive analysis of what was causing them. For a resident with stroke-related paralysis and weakness on one side of her body, falls were a foreseeable and documented risk. The record does not show what interventions, if any, were considered or implemented before the October 3 fall that sent her to the hospital.
The inspection was a complaint survey, completed October 17, 2025. Green Lea Senior Living is located at 115 North Lyndale in Mabel, a small town in southeastern Minnesota near the Iowa border.
The resident who fell five times in six days and was hospitalized with a brain bleed is not named in the inspection record. Her condition after hospitalization is not described. What the record shows is that she arrived at Green Lea with a body already weakened by stroke, fell repeatedly without triggering the kind of systematic review that might have caught something, and then fell a fifth time and was sent away by ambulance while the staff she left behind sorted out, imperfectly, who was supposed to tell whom.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Green Lea Senior Living from 2025-10-17 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 24, 2026 · Our methodology
Green Lea Senior Living in MABEL, MN was cited for violations during a health inspection on October 17, 2025.
She fell on September 26, September 28, September 30, and October 1.
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.