Green Lea Senior Living: Care Plan Failures Put Resident at Risk - MN
One of them, identified in inspection records as NA-E, told her colleague she didn't think the full body lift was correct for this resident. But when she had checked the care plan, it didn't say how the resident was supposed to be transferred at all. So NA-G, the other aide, left the room to find out.
What she found, after tracking down the physical therapy department directly, was a handwritten recommendation dated October 8. The resident, identified only as R1, had returned from the hospital that day. Therapy had cleared her for a sit-to-stand lift instead of a full body mechanical lift, with two staff assisting, her right hand guided up to the bar, and her right foot carefully positioned. The change had been documented. Copies had been distributed. A nurse had signed for the communication form.
The care plan had never been updated.
NA-G told the inspector that the last time she had worked, R1 required a full body lift. Nobody had told her that changed. It wasn't in report. It wasn't on the therapy clipboard. She had to go ask therapy herself to get a piece of paper that should have been in the care plan six days earlier.
"Not having a resident's care plan updated timely could put the resident at risk for being transferred incorrectly and causing an injury," NA-G told the inspector.
The physical therapist explained the process during an interview on October 14. When therapy changes a resident's transfer status, staff complete a Rehab Communication Form and distribute four copies: one to the director of nursing, one to the assistant director of nursing, one to nurses, and one to nursing assistants. A licensed nurse signs for the form when it is handed off. The therapist said she would have expected R1's care plan to be updated as soon as that form reached nursing.
The form had reached nursing on October 8. The inspection took place on October 10.
The director of nursing, interviewed that same afternoon, confirmed the care plan had not been updated to reflect the transfer change. She also confirmed it had not been updated to include R1's fall risk, fall prevention interventions, low bed placement, or fall mat, all of which should have been documented after the hospital return.
"R1's care plan should have been updated as soon as possible," the director of nursing said, "but I just have not gotten to doing it yet."
The facility's own policy, though undated, states that any change in a resident's physical functioning identified after the initial care plan must be incorporated into an updated summary. The MDS coordinator, a registered nurse, told inspectors that baseline care plans should include fall risk and fall prevention interventions and should be updated as soon as possible so staff know how to properly care for a resident.
None of that had happened for R1.
What the inspection captured, in real time, was the gap between a system that looked like it was working and a resident who was one miscommunication away from being lifted the wrong way. The therapist had done her part. The communication form existed. A nurse had signed for it. But the care plan, the document nursing assistants actually consult at the bedside, still showed a resident who needed a full body mechanical lift.
NA-G found the right answer only because NA-E paused and said something felt off. If she hadn't, the inspection report does not say what would have happened next.
The complaint inspection at Green Lea Senior Living was completed October 17, 2025. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents.
R1's care plan, as of the day inspectors observed the transfer attempt, still had not been corrected.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 8, 2026 · Our methodology
GREEN LEA SENIOR LIVING in MABEL, MN was cited for violations during a health inspection on October 17, 2025.
One of them, identified in inspection records as NA-E, told her colleague she didn't think the full body lift was correct for this resident.
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.