Green Lea Senior Living: Toileting Failures Cause Falls - MN
"Sometimes I pee the chair, recliner, and bed," she told inspectors on the morning of October 17. "This makes me feel terrible and like a baby."
She had fallen four times since early September. On September 4. On October 2. On October 14. On October 15. Documentation from each incident identified toileting as a contributing cause. After four falls in six weeks, all tied to the same problem, the facility still had not completed a bladder assessment or developed an individualized toileting plan for her.
"Sometimes I cannot find the call light and just have to try and take myself to the bathroom," she said, "but I fall when I try and I just want to be able to keep my bladder control like I did when I first came."
The resident, identified in inspection records as R4, had been continent when she arrived at Green Lea. Her care plan noted she had a self-performance deficit related to confusion, impaired balance, and Huntington's Disease. It called for staff to transfer her to the toilet with assistance and noted she could wipe herself when finished. What it did not include, for weeks, was any individualized toileting schedule based on her actual needs.
The director of nursing told inspectors she believed the resident's worsening incontinence happened because staff did not know how often she should be toileted. She reviewed the record during the interview and acknowledged the documentation showed R4 had progressed to frequently incontinent of urine.
A new intervention, a two-hour toileting schedule while awake and after each meal, was added to R4's fall care plan on October 15. That was two days before inspectors arrived. There was no bladder assessment in the record, no voiding diary, no documented basis for why two hours was the right interval for this particular resident with this particular condition.
The licensed practical nurse on staff told inspectors the standard approach was to toilet all residents every two hours. She was unsure how staff were tracking whether that was actually happening.
A nursing assistant said staff tried to toilet every resident every two hours but was not aware R4 had any different schedule. She had noticed R4 was having more incontinent episodes lately. She knew R4 would sometimes try to take herself to the bathroom.
R4 told inspectors directly what the nursing assistant and the LPN and the director of nursing could not fully account for in their interviews: staff thought she only needed to go once a day. "I need to go more than that," she said.
The facility's own incontinence policy states that residents who are continent on admission must receive appropriate treatment and assistance to maintain continence. R4 arrived continent. She was no longer.
Green Lea Senior Living is a small facility on North Lyndale in Mabel, a town in the southeastern corner of Minnesota. The inspection was conducted in response to a complaint.
The deficiency was cited at a level of minimal harm or potential for actual harm. That is the lowest tier of the harm scale CMS uses. It does not account for what R4 described when she sat across from an inspector and cried, or for what it means to fall four times in six weeks while reaching for a call light in the dark.
She said she just wanted to keep her bladder control like she had when she first came.
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.
"Sometimes I pee the chair, recliner, and bed," she told inspectors on the morning of October 17.
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.