Green Lea Senior Living: Infection Control Failure - MN
The resident, identified in inspection records only as R1, has hemiplegia and hemiparesis, paralysis and partial weakness on one side of her body following a stroke. She cannot transfer herself or use the toilet without help. She is, according to her assessment records, fully cognitively intact. She knew exactly what was happening.
On the afternoon of October 16, 2025, R1 told nursing assistant NA-F and a registered nurse that she needed to use the bathroom. NA-F wheeled her to her room. Before touching R1 or any of her belongings, NA-F pulled on gloves without first washing her hands. She used a stand-assist device to move R1 to a bedside commode. R1 urinated and had a bowel movement.
NA-F instructed R1 to stand. Once R1 was upright, NA-F used her gloved right hand and wet wipes to clean stool from R1's body. Then, without removing those gloves, she began pulling R1's pants back up.
A state surveyor was in the room and prompted NA-F to wash her hands.
NA-F's response: "I do that once I am done with all of my cares."
She kept the gloves on. She finished pulling up R1's pants. Then she grabbed R1's wheelchair by the armrest with the same gloved hand and moved it into position so R1 could sit down. R1 sat. NA-F removed both gloves and, still without washing her hands, folded R1's blanket and placed it on the bed.
Then she washed her hands.
Twenty-seven minutes after the observation, a surveyor interviewed NA-F about what had happened. NA-F acknowledged that anything touched with soiled gloves could be contaminated. She had already touched the wheelchair armrest. She had already touched the blanket.
Her earlier explanation for why none of it mattered: "My hands are not dirty, because the wipe was between R1's bowel movement and my glove."
The registered nurse who had been present during R1's care, RN-C, was interviewed the following day. RN-C said NA-F should have performed hand hygiene before entering the room, before putting on gloves, after removing them, and should have pulled off the contaminated gloves immediately after cleaning R1, washed her hands, and put on a fresh pair before touching anything else.
The director of nursing said the same. Her expectation of staff, she told inspectors, was hand hygiene before and after any care, before and after glove removal. Gloves come off after peri care. Hands get washed. New gloves go on.
None of that happened.
Green Lea's own hand hygiene policy, though undated, instructs staff to perform proper hand hygiene when moving from a contaminated body site to a clean body site during resident care. NA-F moved from cleaning stool to pulling up pants to gripping a wheelchair to handling a blanket. The policy did not appear to factor into any of it.
The violation was cited at a level of minimal harm or potential for actual harm, meaning inspectors concluded R1 was not known to have been sickened by what occurred. The finding covered one of three residents observed for hand hygiene during the inspection.
R1 sat in her wheelchair at the end of it, cognitively intact, having watched a staff member clean her after a bowel movement and then touch her chair and her blanket without once washing her hands.
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 25, 2026 · Our methodology
Green Lea Senior Living in MABEL, MN was cited for violations during a health inspection on October 17, 2025.
She cannot transfer herself or use the toilet without help.
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.