Green Lea Senior Living

Review of R1's fall incidents identified 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. R1's fall incident report dated 10/3/25 at 9:24 a.m., identified R1 was found on floor between door and bed. 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.ˆˆR1 was sent to emergency department (ED) for evaluation.

There was no indication a comprehensive fall investigation/analysis was completed. ˆˆ R1's progress note dated 10/3/25 at 9:38 p.m., identified 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 R1 was being kept for observation for a brain bleed.ˆ

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 R1 and was informed that R1 was being admitted to the hospital due to a brain bleed.ˆˆLPN-A informed the assistant director of nursing (ADON) about R1's brain bleed.ˆˆLPN-A assumed the ADON informed the administrator of R1's brain bleed following the fall; therefore, she did not report R1's injury to the administrator immediately.ˆˆLPN-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 R1's fall with serious injury had not been reported to the SA when the facility learned 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 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, R1's fall with serious injury should have been reported within two hours of the facility's knowledge of the injury and that 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.ˆ - 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.

245536 10/17/2025

Green Lea Senior Living 115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

During an interview on 10/17/25 at 1:04 p.m., Minimum Data Set Coordinator/registered nurse (MDS-RN) stated R1's MDS with an ARD date of 9/30 was not accurate.ˆˆSection J1800 should have been marked that R1 had falls since admission, however, was marked that R1 did not have any falls since admission.ˆˆMDS-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 R1's falls on 9/29/25, 9/28/25 and 9/30/25.ˆ

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.

245536 10/17/2025

Green Lea Senior Living 115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

During an interview on 10/14/25 at 3:07 p.m., physical therapist (PT) stated recommendations for a resident the use a Rehab Communication Form and give four copies to the facility-one for director of nursing, one for the assistant director of nursing, one for nurses, one for nursing assistants.

Therapy does have a licensed nurse sign for the communication form when it is dispersed to nursing. PT stated R1 was changed from a total mechanical lift on 10/8/25 when she returned from the hospital and would have expected R1's care plan to be updated as soon as the communication form was given to nursing.

During an interview with Minimum Data Set Coordinator-RN (MDS-RN) stated baseline care plans should include a resident's fall risk and fall prevention interventions and should be updated as soon as possible to let staff know how to properly care for a resident.

During an interview on 10/10/25 at 5:25 p.m., director of nursing (DON) stated R1's care plan had not updated to reflect the change in transfer status on 10/8/25, nor been updated to include fall risk, fall prevention interventions, low bed, fall mat. DON further stated, R1's care plan should have been updated as soon as possible, but I just have not gotten to doing it yet.

Review of the facility's Baseline Care Plan Policy undated, identified the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care.Policy Explanation and Compliance Guidelines:1.

The baseline care plan will:a. Be developed within 48 hours of a resident's admission.b.

Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i.

Initial goals based on admission orders. ii.

Physician orders. iii.

Dietary orders. iv.

Therapy services. v.

Social services. vi. PASARR recommendation, if applicable.2.

The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable.a.

Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives.b.

Interventions shall be initiated that address the resident's current needs including: i.

Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii.

Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. iii.

Any special needs such as for IV therapy, dialysis, or wound care.c.

Once established, goals and interventions shall be 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.

245536 10/17/2025

Green Lea Senior Living 115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

comprehensively assessed or had any causal analysis completed for the falls prior to 10/15/25 to

jeopardy to resident health or Fall Risk, Managing Policy dated 10/15/25, identified the staff will identify interventions related to safety the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Resident-Centered Approaches to Managing Falls and Fall Risk:

of falls for each resident at risk or with a history of falls.

Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling or indicate why those medications could not be tapered or stopped, even for a trial period, as needed. If falling recurs despite initial interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable.

Staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling, as appropriate.

Position-change alarms may be used to assist the staff in identifying patterns and routines of the resident.

The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

Monitoring Subsequent Falls and Fall Risk: If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously 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.

245536 10/17/2025

Green Lea Senior Living 115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

During an observation and interview on 10/17/25 at 8:30 a.m.,

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. 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. 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 R4 had a different toileting schedule. NA-G stated R4 had been having more incontinent episodes lately. 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 R4 was continent on admission and did have a toileting schedule added to her care plan on admission. DON reviewed R4's record, she explained the documentation identified 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 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.

245536 10/17/2025

Green Lea Senior Living 115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

During an interview on [DATE] 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:

• 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.

245536 10/17/2025

Green Lea Senior Living 115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

appropriate.

This data is reported to the QAA committee.b.

The QAA committee analyzes the data in

Mode and Effect Analysis, etc.) (specify one or more methods) to help identify the root cause of the

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.

245536 10/17/2025

Green Lea Senior Living 115 North Lyndale, Rr 2 Box 49 Mabel, MN 55954

During an observation and interview on 10/16/25 at 4:11 p.m., R1 informed nursing assistant (NA)-F and registered nurse (RN)-C that she needed to go to the bathroom. NA-F pushed R1 to her room.

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

Once standing, NA-F used her gloved right hand and wet wipes to clean R1's bottom from any stool.ˆOnce cleaned, NA-F started to pull up 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 R1's pants up with the same gloved hands used for R1's peri care. NA-F stated, My hands are not dirty, because the wipe was between R1's bowel movement and my glove. NA-F grabbed R1's wheelchair by the left arm rest with her right hand and moved it behind R1 so she could sit down. R1 then sat down in the wheelchair. NA-F removed her gloves from both hands, she did not perform hand hygiene prior to folding 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 R1's room, before and after removing gloves, and removed her contaminated gloves after performing peri care and performed hand hygiene.ˆˆ

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.ˆˆ 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.