Green Lea Senior Living

In the surveyor’s words

From the most serious findings on record at Green Lea Senior Living, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 17, 2025

  Based on observation, interview, and document review the facility failed to comprehensively assess falls for root cause, implement appropriate interventions and implement/revise the care plan to prevent and/or reduce the risk of fall with major injury for 2 of 3 residents (R1, R4) who had falls. This resulted in an immediate jeopardy (IJ) for R1 who sustained a resulted in a subarachnoid hemorrhage (type of brain bleed) and was hospitalized .The IJ began on 9/30/25 after R1's third fall with no completion of a causal analysis or implementation of fall interventions which resulted in and/or could have mitigated the risk of R1's fall on 10/3/25 fall with major injury that required 5-day hospitalization and two subsequent falls on 10/8/25 upon readmission to the facility. […]

• Immediate jeopardy, isolatedF689Sep 26, 2025

  Based on interview and document review the facility failed to ensure safe transfers for 1 of 1 resident (R1) while using a mechanical lift and did not follow the correct procedure for applying the straps of the sling to the lift. As a result, the sling became unhooked from the mechanical lift, R1 fell to the floor, and sustained a hematoma (collection of blood outside a blood vessel) to the back of her head, and fractures to the left 3rd, 4th, and 6th ribs which resulted in an immediate jeopardy (IJ).The IJ began on 9/15/25 when facility staff failed to follow manufacturer directions for connecting a sling to a mechanical lift and R1 fell from the lift. […]

• Immediate jeopardy, isolatedF678Aug 5, 2021

  Based on observation, interview and document review, the facility failed to ensure a system for receiving, transcribing and communicating code status orders for cardiopulmonary resuscitation (CPR) for 1 of 12 residents (R228) reviewed for advanced directives and wishes for life sustaining treatment. This failure resulted in an immediate jeopardy (IJ) when it was identified R228 had conflicting advanced directives and could result in a resident's wishes not being honored as stated in their code status orders. This failure had the potential to effect any resident having their code status reviewed upon admission, quarterly or as needed. […]

• Actual harm, isolatedF689Jul 21, 2026

  Based on interview and record review, the facility failed to implement necessary interventions and provided adequate supervision consistent with the person-centered care plan for 1of 1 resident (R14) reviewed. This deficient practice resulted in actual harm when R14 was left unattended in a shower chair, lost balance, fell to the floor, and sustained a forehead laceration requiring eight sutures and an acute subdural hemorrhage (brain bleed). The noncompliance that began on 6/17/26 was corrected prior to the start of survey when the facility implemented a corrective action plan on 6/22/26. […]

• No harm, potential for more than minimal, widespreadF839Oct 17, 2025

  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] identified the following:-NA-B's nurse aide certificate expired on [DATE].-NA-H's nurse aide certificate expired on [DATE].-NA-I's nurse aide certificate expired on [DATE].-NA-L's nurse aide certificate expired on [DATE].The facility's employee records were reviewed on [DATE] and identified NA-B, NA-H, NA-I, and NA-L were scheduled and completed shifts from [DATE] thought [DATE] with an… […]