Green Lea Senior Living

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and document review the facility failed to ensure call lights were accessible and within reach for 2 of 3 residents (Resident R2 and Resident R5) reviewed for fallsFindings include:Resident R2's face sheet dated 10/16/25, identified diagnoses of Parkinson's disease (a progressive brain disorder that affects movement, causing symptoms like tremors, stiffness, and slowed movements) and dementia (a decline in memory, thinking, reasoning and problem solving). Resident R2's Minimum Data Set (MDS) dated [DATE REDACTED], identified Resident R2 had severe cognitive impairment, needed extensive assistance for all transfers. Resident R2's fall focus care plan identified Resident R2 was at risk for falls related to poor balance and unaware of safety risks. Intervention of call light to be within reach. During and observation and interview on 10/10/25 at 4:05 p.m., Resident R2 was sitting in his room in his wheelchair with a tray table in front of him.??Resident R2 asked for surveyor to come into his room, there was a drinking cup on the floor to Resident R2's left side. Resident R2 asked surveyor to pick up his glass for him. Resident R2's call light was sitting on the floor in front of the recliner about two feet behind Resident R2.??Resident R2 stated he did not have my button.??Nursing assistant (NA)-A entered Resident R2's room at 4:10 p.m. NA-A identified Resident R2's call light should have been placed within Resident R2's reach because he tended to get agitated and may try to self-transfer if the call light is not accessible.? Resident R5's face sheet dated 10/16/25, identified diagnosis of Alzheimer's Disease (a progressive brain disorder characterized by gradual decline in memory, thinking, and language skills). Resident R5's Minimum Data Set, dated [DATE REDACTED], identified Resident R5 had severe cognitive impairment and needed maximum assistance for transfers. Resident R5's fall focus care plan identified Resident R5 was at risk for falls related to limited physical mobility. Interventions included to have call light within reach. During an observation and interview on 10/14/25 at 3:58 p.m., Resident R5 was sitting in a recliner in her room and had requested the surveyor to come into her room to pick of her cup and chocolate pieces that were located on the floor next to her feet. Resident R5 explained she could not find her button. Her call light was on the floor next to her left foot, not within in reach. NA-F entered Resident R5's room at 4:06 p.m. NA-F stated Resident R5's call light was not within reach and should have been placed where Resident R5 could reach it so she could ask for help. During an interview on 10/17/25 at 3:05 p.m., director of nursing (DON) stated all residents should always have call lights within reach and her expectation would be for all staff to ensure the call lights are place appropriately.???? Review of the facility's Call Light: Accessibility and Timely Response Policy undated, identified?the purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.?Policy Explanation and Compliance Guidelines included:?Staff will ensure the call light is within reach of resident and secured, as needed.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Lea Senior Living

115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interview and document review the facility failed to timely report to the State Agency (SA) a fall with serious injury for 1 of 1 resident (Resident R1) who had multiple prior falls without fall assessments and implementation of appropriate fall interventions to prevent/mitigate risk of re-current falls. Resident R1's face sheet dated 10/15/25, identified diagnoses of hemiplegia (a condition that causes paralysis or weakness on one side of the body) and hemiparesis (partial weakness on one side of the body making it difficult to perform daily activities) following cerebral infarction (stroke). Review of Resident R1's fall incidents identified Resident R1 had falls on 9/26/25, 9/28/25, 9/30/25, and 10/1/25; no comprehensive analysis for causal factors were completed after each fall nor were appropriate interventions to prevent/mitigate the risk of falls and falls with major injury. Resident R1's fall incident report dated 10/3/25 at 9:24 a.m., identified Resident R1 was found on floor between door and bed. Resident R1 had an injury above right eye that was swollen and bleeding, and two skin tears on right forearm.

Predisposing factors of restless, gait imbalance, and weakness.??Resident R1 was sent to emergency department (ED) for evaluation. There was no indication a comprehensive fall investigation/analysis was completed. ?? Resident R1's progress note dated 10/3/25 at 9:38 p.m., identified Resident R1 was sent out via ambulance earlier in the day due to a fall with head injury and at 2:57 p.m., the nurse called the hospital for an update and was informed that Resident R1 was being kept for observation for a brain bleed.? During an interview on 10/15/25 at 11:54 a.m., licensed practical nurse (LPN)-A stated on 10/3/25 she had called the hospital to check on Resident R1 and was informed that Resident R1 was being admitted to the hospital due to a brain bleed.??LPN-A informed the assistant director of nursing (ADON) about Resident R1's brain bleed.??LPN-A assumed the ADON informed the administrator of Resident R1's brain bleed following the fall; therefore, she did not report Resident R1's injury to the administrator immediately.??LPN-A explained she was under the impression that the incident needed to be reported to

the administrator within two hours and was unaware of the reporting requirement to the SA. During an

interview on 10/14/25 at 4:28 p.m., administrator stated Resident R1's fall with serious injury had not been reported to the SA when the facility learned Resident R1 sustained a brain bleed following a fall and should have been reported within two hours. Administrator was not aware the rationale the fall with serious injury was not reported to the SA in a timely manner or not at all. During an interview on 10/14/25 at 4:35 p.m., director of nursing (DON) stated when Resident R1 had a fall on 10/3/25 and sustained a brain bleed the ADON was in charge due to DON being on vacation, however, Resident R1's fall with serious injury should have been reported within two hours of the facility's knowledge of the injury and that Resident R1's fall was not reported to the SA. Review of the facility's Abuse Investigation and Reporting Policy dated 4/17/25, identified all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulation) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.? - An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: two (2) hours if

the alleged violation involves abuse OR has resulted in serious bodily injury; or twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Lea Senior Living

115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and document review the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 of 3 residents (Resident R1) reviewed for residents who had falls. Findings include:Resident R1's face sheet dated 10/15/25, identified diagnoses of hemiplegia (a condition that causes paralysis or weakness on one side of the body) and hemiparesis (partial weakness on one side of the body making it difficult to perform daily activities) following cerebral infarction (stroke). Resident R1's fall incident report dated 9/26/25 at 2:00 p.m., identified Resident R1 had an unwitnessed fall from wheelchair in room. Resident R1 stated she was trying to get to the bathroom. Resident R1's progress note dated 9/28/25 at 7:17 p.m., indicated Resident R1 fell from bed onto cushioned mat on

the floor. Resident R1's progress note dated 9/30/25 at 9:47 p.m., identified Resident R1 had a fall at 8:50 p.m. Resident R1 was found lying on the fall mat next to her bed. Resident R1 had removed brief and only had on gripper sock on.? Resident R1's 5-day MDS assessment with an assessment reference date of 9/30/25, identified section J1800 was coded as Resident R1 had not had any falls since admission/entry even though Resident R1's records identified three falls since admission.

During an interview on 10/17/25 at 1:04 p.m., Minimum Data Set Coordinator/registered nurse (MDS-RN) stated Resident R1's MDS with an ARD date of 9/30 was not accurate.??Section J1800 should have been marked that Resident R1 had falls since admission, however, was marked that Resident R1 did not have any falls since admission.??MDS-RN stated that he referenced the Risk Management fall incident reports and reviews the progress notes during the ARD window, however, must have missed seeing Resident R1's falls on 9/29/25, 9/28/25 and 9/30/25.? Review of the facility's Resident Assessments Policy dated 10/2023, identified the following:

A comprehensive assessment of each resident is completed at intervals designed by OBRA regulations and PPS requirements. Data from the MDS is submitted to the Internet Quality Improvement Evaluation System (IQEIS) as required. Policy interpretation and implementation included the following: Information in

the MDS assessments will consistently reflect information in the progress notes, plan of care, and resident

observations/interviews.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Lea Senior Living

115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

documented in the designated format.3. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed.4. In the event that the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable. This will be provided by the MDS nurse/designee by the completion date of the comprehensive care plan.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Lea Senior Living

115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls, as needed.

Documentation: - The licensed nurse shall promptly initiate and document the accident or incident. Licensed nurses will update the care plan with the new fall intervention post fall.- Licensed nurse will update

the resident's Kardex with fall intervention. - Licensed nurse will document the new fall intervention in the nursing communication binder for clinical staff to review. - Licensed nurse will complete a Morse Fall Scale with each new fall. -IDT will meet on every business day to review resident falls and interventions. Progress note will be made in the residents' record of this review.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Lea Senior Living

115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

living (ADL) focus care plan, initiated on 10/1/25, identified Resident R4 had a self-performance deficit related to confusion, impaired balance, and Huntington's Disease. Corresponding interventions included: dependent

on staff for transferring with gait belt and walker, transfer to toilet with assist of one and able to wipe herself

after she is done. Resident R4's care plan did not identify an individualized toileting plan. Resident R4's fall focus care plan identified a new intervention on 10/15/25 to toilet every two hours while awake and after each meal however Resident R4's record did not include a corresponding comprehensive bladder assessment and/or voiding diary that identified how that toileting schedule was determined.In review of Resident R4's revealed although incident reports identified Resident R4 had four falls (9/4/25, 10/2/25, 10/14/25, and 10/15/25) in which documentation indicated toileting as a causal factor there was no indication of a comprehensive bladder assessment was completed to determine type and/or possible changes in bladder function. Additionally, there was no indication of assessment to determine an appropriate toileting program/schedule. During an observation and interview on 10/17/25 at 8:30 a.m., Resident R4 stated staff did not offer to take her to the bathroom regularly and further stated they think I only need to go once per day, but I need to go more than that. Sometimes I pee the chair, recliner, and bed. This makes me feel terrible and like a baby. Resident R4 then began to cry and stated, Sometimes I cannot find the call light and just have to try and take myself to the bathroom, but I fall when I try and I just want to be able to able to keep my bladder control like I did when I first came.During an

interview on 10/16/15 at 9:22 a.m., licensed practical nurse (LPN)-A stated that the standard for toileting people is that all residents are toileted every two hours. LPN-A was unsure how staff were keeping track of how often residents were toileted. Resident R4 did not have a toileting plan in place prior to 10/15/25.During an

interview on 10/10/25 at 4:20 p.m., nursing assistant (NA)-G stated staff tried to toilet every resident every two hours. NA-G was not aware if Resident R4 had a different toileting schedule. NA-G stated Resident R4 had been having more incontinent episodes lately. Resident R4 would normally ask for assistance to use the bathroom however would attempt to take herself at times. During an interview on 10/17/25 at 3:35 p.m., director of nursing (DON) stated Resident R4 was continent on admission and did have a toileting schedule added to her care plan on admission. DON reviewed Resident R4's record, she explained the documentation identified Resident R4's incontinence had worsened to frequently incontinent of urine. DON thought the increase in incontinence was because staff were not aware of how often Resident R4 should be toileted. Review of the facility's Incontinence Policy undated, identified the facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Lea Senior Living

115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0839

Employ staff that are licensed, certified, or registered in accordance with state laws.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and document review the facility failed to ensure 4 of 7 facility employed nursing assistants' (nursing assistant (NA)-B, NA-H, NA-I, and NA-L) certificates were current with the states nursing assistant registry. This had the potential to affect all thirty-two residents that resided in the facility.Findings include:

Review of the State of Minnesota Nursing assistant registry on [DATE REDACTED] identified the following:-NA-B's nurse aide certificate expired on [DATE REDACTED].-NA-H's nurse aide certificate expired on [DATE REDACTED].-NA-I's nurse aide certificate expired on [DATE REDACTED].-NA-L's nurse aide certificate expired on [DATE REDACTED].The facility's employee records were reviewed on [DATE REDACTED] and identified NA-B, NA-H, NA-I, and NA-L were scheduled and completed shifts from [DATE REDACTED] thought [DATE REDACTED] with an expired nurse aide certificate.During an interview on [DATE REDACTED] at 12:25 p.m., director of nursing (DON) stated she was not aware that NA-B, NA-H, NA-I, and NA-L had been working without a current nursing assistant certificate since [DATE REDACTED]. DON further stated she was not responsible for ensuring that staff had a current license/certificate and was unsure who was responsible for ensuring staff maintained their certification and/or professional licenses. During an interview on [DATE REDACTED] at 12:05 p.m., administrator stated she had not been aware that NA-B, NA-H, NA-I and NA-L nursing assistant certificates expired and that the facility did not have process in place to ensure verification of licensed/certified staff's credentials are verified that they are current. Administrator further stated the responsibility to ensure the licenses/certificates are currently would be ultimately her responsibility and it was not completed.Review of the facility's License Verification Policy undated, identified all personnel that require a license, or certification shall be verified through the appropriate issuing agency. Policy Explanation and Compliance Guidelines included the following: 1. The Human Resources Director, or designee, is responsible for maintaining and ensuring the validity and current status of individual certification/licensure.2. An individual will not be employed and or/will be terminated from employment (whichever case may apply) if:a. The individual has lost licensure/certification for any reason, orb. The individual has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.3. Any licensed/certified employee is responsible for maintaining continuing education hours as required for current licensure/certification status. 4. Any licensed/certified employee is responsible for submitting verification of licensure/certification renewal to Human Resources prior to expiration.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Lea Senior Living

115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Assurance (QAA) Committee that is responsible for coordinating and evaluating activities under the facility's QAPI program.2. The QAA Committee utilizes a systematic approach to performance improvement, including analysis of data, corrective action, and performance tracking.3. Data analysis -a. The facility draws data from multiple sources, including input from all staff, residents, families, and others as appropriate. This data is reported to the QAA committee.b. The QAA committee analyzes the data in order to identify or better understand a problem.c. Once a potential problem is identified, the committee utilizes a systematic approach (e.g., Five Whys, flowcharting, fishbone diagram, Failure Mode and Effect Analysis, etc.) (specify one or more methods) to help identify the root cause of the problem.d. As corrective actions are taken, the committee continues to collect and analyze data to determine the effectiveness of any changes.4.

Corrective action -a. Once the root cause of a problem is identified, the QAA committee oversees the development of an appropriate corrective action. An appropriate corrective action is one that addresses the underlying cause of the issue comprehensively, at the systems level.b. Corrective action plans include: i. A definition of the problem - which includes determining contributing causes of the problem. ii. Measurable goals. iii. Step-by-step interventions to correct the problem and achieve established goals; and iv. A description of how the QAA committee will monitor to ensure changes yield the expected results.c. Example corrective actions may include, but are not limited to: i. Introducing new equipment or products, with staff input, that specifically address the identified problem. ii. Updating policies and procedures. iii. Posting reminders or posters depicting desired behaviors. iv. Providing education and verifying competency following the education. v. Eliminating barriers to following facility policies and procedures. vi. Observing staff members and providing feedback on their performance of new practices. vii. Convening a Performance Improvement Project (PIP) to improve a systematic problem or improve quality in absence of a problem.d.

The QAA committee uses the Plan, Do, Study, Act (PDSA) cycle of improvement for testing any changes within a PIP. i. Plan: developing a plan related to the change that will be tested ii. Do: carrying out the plan iii. Study: observing and analyzing data collected, learning from any consequences iv. Act: making a decision regarding the change, such as to adopt, modify, or abandon the change and start overe. Multiple PDSA cycles may be implemented until the desired performance goals have been met.5. The facility must conduct distinct performance improvement projects, based on the scope and complexity of facility services and available resources, identified in the facility assessment.6. The facility must conduct at least one improvement project annually that focuses on high-risk or problem-prone areas, identified by the facility through data collection and analysis.7. Performance Tracking -a. Once actions are implemented, the facility continues to track performance to ensure that improvements are realized and sustained.b. A combination of process and outcome measures are used to measure success following the implementation of change. i.

Process measures look at the specific steps in a process that lead, either positively or negatively, to a particular outcome. ii. Outcome measures track results. iii. Performance on the measures is discussed in QAA Committee meetings. Data is analyzed, and the process continues as appropriate.c. At least annually,

the facility conducts a self-assessment to determine the facility's performance improvement culture.

Corrective action is taken as appropriate.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Green Lea Senior Living

115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, interview, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 1 of 3 residents (Resident R1) observed for handwashing/hand hygiene during toileting/incontinence care. Findings include: Resident R1's face sheet dated 10/15/25, identified diagnoses of hemiplegia (a condition that causes paralysis or weakness on one side of the body) and hemiparesis (partial weakness on one side of the body making it difficult to perform daily activities) following cerebral infarction(stroke). Resident R1's minimum data set (MDS) dated [DATE REDACTED], identified Resident R1 was dependent for all transfers and toileting, and?was cognitively intact. During an observation and interview on 10/16/25 at 4:11 p.m., Resident R1 informed nursing assistant (NA)-F and registered nurse (RN)-C that she needed to go to the bathroom.

NA-F pushed Resident R1 to her room. Upon entering Resident R1's room, NA-F applied gloves without performing hand hygiene. NA-F used a stand-aide to transfer Resident R1 to the commode; she voided and had a bowel movement.

NA-F instructed Resident R1 to stand. Once standing, NA-F used her gloved right hand and wet wipes to clean Resident R1's bottom from any stool.?Once cleaned, NA-F started to pull up Resident R1's pants without removing her gloves and perform hand hygiene. When surveyor prompted NA-F to perform hand hygiene, NA-F stated, I do that once I am done with all of my cares. NA-F continued to pull Resident R1's pants up with the same gloved hands used for Resident R1's peri care. NA-F stated, My hands are not dirty, because the wipe was between Resident R1's bowel movement and my glove. NA-F grabbed Resident R1's wheelchair by the left arm rest with her right hand and moved

it behind Resident R1 so she could sit down. Resident R1 then sat down in the wheelchair. NA-F removed her gloves from both hands, she did not perform hand hygiene prior to folding Resident R1's blanket. After NA-F placed the blanket on the bed, NA-F then washed her hands. During a follow up interview on 10/16/25 at 4:38 p.m., NA-F stated the risk of not removing gloves after performing peri care after a bowel movement could cause anything that was touched with the soiled gloves could be contaminated. During an interview on 10/17/25 at 4:35 p.m., registered nurse (RN)-C stated NA-F should have performed hand hygiene prior to entering Resident R1's room,

before and after removing gloves, and removed her contaminated gloves after performing peri care and performed hand hygiene.?? During an interview on 10/17/25 at 3:27 p.m., director of nursing (DON) stated her expectation of staff would be to perform hand hygiene before and after any cares, before and after removal of gloves. Gloves should be removed after performing peri care and hand hygiene performed and new gloves applied.?? Review of Hand Hygiene Policy undated, identified that all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene is indicated and will be performed when, during resident care, moving from a contaminated body site to a clean body site.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet