Green Lea Senior Living: Hand Hygiene Failure - MN
The resident, who had suffered a stroke and was fully dependent on staff for transfers and toileting, was alert and aware of everything happening around her. She had hemiplegia and hemiparesis, meaning one side of her body was paralyzed or weakened, and she could not manage any of this care herself.
On October 16, 2025, just after 4 p.m., inspectors watched as nursing assistant NA-F pushed the resident to her room without first washing her hands or applying gloves. NA-F put gloves on only after entering the room, then transferred the resident to a commode using a stand-aide. The resident urinated and had a bowel movement. NA-F cleaned the resident's bottom with wet wipes, then began pulling the resident's pants up without removing the soiled gloves.
When an inspector prompted NA-F to wash her hands, NA-F said: "I do that once I am done with all of my cares." She continued pulling up the pants. Then she said: "My hands are not dirty, because the wipe was between R1's bowel movement and my glove."
NA-F grabbed the resident's wheelchair with her gloved right hand, moved it into position, and let the resident sit down. Only then did she remove the gloves. She still did not wash her hands. She folded the resident's blanket bare-handed, placed it on the bed, and then walked to the sink.
Twenty-seven minutes later, NA-F acknowledged in an interview what the risk was. Whatever the soiled gloves had touched, she said, could be contaminated.
The registered nurse present during the care, RN-C, told inspectors the next day that NA-F should have washed her hands before entering the room, before putting on gloves, after removing them, and immediately after finishing peri care. The director of nursing said the same.
The stroke survivor sat in her wheelchair, cognitively intact, and waited while the gloves stayed on.
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.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
GREEN LEA SENIOR LIVING in MABEL, MN was cited for violations during a health inspection on October 17, 2025.
The resident, who had suffered a stroke and was fully dependent on staff for transfers and toileting, was alert and aware of everything happening around her.
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.