Inspection Report

Green Lea Senior Living: MDS Assessment Failures - MN

June 24, 2026

Mabel, MN

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The resident, identified in inspection records only as R1, had suffered a stroke. She had hemiplegia and hemiparesis, conditions that left one side of her body paralyzed or weakened, making the kind of independent movement she was attempting, getting to a bathroom, getting out of bed, especially dangerous. Her care needs were already documented. What wasn't documented, on the form that matters most to federal oversight, was what kept happening to her.

The first fall was September 26, 2025, at 2:00 in the afternoon. An incident report noted it was unwitnessed. R1 had been in her wheelchair in her room. She told staff she was trying to get to the bathroom.

Two days later, on September 28 at 7:17 in the evening, a progress note recorded that she had fallen from her bed onto a cushioned mat on the floor.

September 30, at 8:50 at night, staff found her lying on the fall mat next to her bed again. She had removed her brief. She had one gripper sock on.

That same date, September 30, was the assessment reference date for R1's five-day Minimum Data Set evaluation, the standardized federal form nursing homes use to document resident condition and care needs. The MDS feeds into Medicare's quality reporting systems and shapes care planning. Section J1800 of that form asks whether a resident has had any falls since admission or the prior assessment.

Green Lea's MDS coordinator checked the box indicating she had not.

When a federal inspector sat down with the MDS coordinator, a registered nurse, on October 17, the nurse did not dispute what the records showed. He said the assessment was not accurate. Section J1800 should have been marked to reflect that R1 had falls, but it wasn't. He said he reviewed fall incident reports and progress notes during the assessment window and must have missed the falls on September 26, September 28, and September 30.

Three falls. The last one on the very day the assessment was due.

The MDS coordinator's own policy, drawn from the facility's resident assessments document dated October 2023, stated that information in MDS assessments would consistently reflect information in progress notes, plan of care, and resident observations. The progress notes existed. The incident report existed. The falls were there to find.

The Centers for Medicare and Medicaid Services cited Green Lea under F0641, the federal tag requiring accurate resident assessments. Inspectors classified the harm level as minimal or potential for actual harm. The deficiency affected few residents.

What the classification doesn't capture is what an inaccurate fall record means for someone in R1's position. A stroke survivor with weakness and partial paralysis who falls three times in four days, twice ending up on a floor mat, once having removed her own brief, is someone whose care plan may need urgent revision. The federal assessment that's supposed to trigger that review said the falls never happened.

The inspection was a complaint survey, meaning someone had raised a concern before investigators arrived. It was completed October 17, 2025.

R1 was found on the floor mat beside her bed. One gripper sock on. The form said she was fine.

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

Editorial Standards

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

Quick Answer

Green Lea Senior Living in MABEL, MN was cited for violations during a health inspection on October 17, 2025.

The resident, identified in inspection records only as R1, had suffered a stroke.

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.

Frequently Asked Questions

What happened at Green Lea Senior Living?

The resident, identified in inspection records only as R1, had suffered a stroke.

How serious are these violations?

Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.

What should families do?

Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in MABEL, MN, (5) Report any new concerns directly to state authorities.

Where can I see the full inspection report?

The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Green Lea Senior Living or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 245536.

Has this facility had violations before?

To check Green Lea Senior Living's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.