Green Lea Senior Living

Inspectors wroteBased on observation, interview and documentation, the facility failed to comprehensively assess and monitor a wound for 1 of 3 residents (R3) reviewed for wound care.

Inspectors wroteBased on observation, interview and document review, the facility failed to establish a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications stored in an emergency medication kit and failed to establish a system to account for medications brought from home and stored in the medication room.

Inspectors wroteBased 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. The administrator and director of nursing (DON) were notified of the IJ on 10/14/25 at 5:31 p.m. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interview and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI)committee identified, investigated, analyzed, and responded to identified resident care issues by developing and implementing action plans for process improvement identified resident care issues related to high number of falls. This had the potential to affect all 32 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure call lights were accessible and within reach for 2 of 3 residents (R2 and R5) reviewed for fallsFindings include: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). R2's Minimum Data Set (MDS) dated [DATE], identified R2 had severe cognitive impairment, needed extensive assistance for all transfers. R2's fall focus care plan identified R2 was at risk for falls related to poor balance and unaware of safety risks. Intervention of call light to be within reach. [...]

Inspectors wroteBased 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 (R1) who had multiple prior falls without fall assessments and implementation of appropriate fall interventions to prevent/mitigate risk of re-current falls. 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 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. [...]

Inspectors wroteBased on interview and document review the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 of 3 residents (R1) reviewed for residents who had falls.

Inspectors wroteBased on observation, interview, and document review the facility failed to assure baseline line care plan addressed safety interventions to prevent/mitigate the risk of decline or injury from falls for 1 of 1 resident (R1) at risk for falls had a fall with major injury.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure received appropriate treatment and services to prevent decline in incontinence and urinary symptoms and further failed to develop and implement an individualized toileting program for 1 of 1 resident (R4) who had a diagnoses of Huntington's disease, was continent upon admission, but had fluctuating symptoms of incontinence, urgency, and frequency.

Inspectors wroteBased on observations, interview, and document review the facility failed to ensure proper handwashing/hand hygiene was implemented for 1 of 3 residents (R1) observed for handwashing/hand hygiene during toileting/incontinence care.

Inspectors wroteBased 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. The Administrator, nurse consultant, and director of nursing (DON) were notified of the past non-compliance (PNC) IJ on 9/26/25 at 11:35 a.m. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure the services of a registered nurse (RN) onsite for 8 consecutive hours/7 days a week. This had the potential to affect all residents who resided at the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain respect and dignity for personal possessions for 1 of 2 residents (R28) reviewed who had his room searched and items removed without consent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate bathing/showering preferences for 1 of 1 resident (R1) reviewed for choices.

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered care plan for 2 of 2 residents (R19, R1) reviewed for care planning.

Inspectors wroteBased on interview and document review, the facility failed to ensure resident's trust account statements were provided on, at least, a quarterly basis. The lack of provided statements had the potential to affect all residents with trust accounts at the care center. During the recertification survey from 6/2/25 to 6/5/25, a facility complaint regarding access to funds was investigated. An incidental finding during this investigation revealed the facility was not sending quarterly statements to residents or resident representatives. During interview on 6/3/25 at 24:45 p.m., business office manager (BOM) stated the facility does not send out quarterly statements. During interview on 6/4/25 at 8:57 a.m., administrator confirmed the facility does not send out quarterly statements. An undated facility policy titled Accounting and Records of Resident funds; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to keep 2 of 2 mechanical lifts in proper working condition.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Facility Assessment identified the facility's staffing needs based on the care needs of the resident population. This had the potential to affect all 32 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ambulation program was provided to maintain mobility to reduce the risk for falls as ordered by physical therapy for 1 of 1 resident (R2) who had a history of falls.

Inspectors wroteBased on interview and document review, the facility failed to maintain a complete, accurately documented, and readily accessible medical record in accordance with accepted professional standards and practices for 1 of 1 resident (R1) reviewed for medical record accuracy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control procedures were followed for 2 of 2 residents (R3 and R4) when staff failed to follow enhanced barrier precautions (EBP) while providing cares and treatment.

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 5 residents (R21, R26, R7) reviewed for immunizations were offered and/or provided the pneumococcal vaccine series (pneumonia vaccine) as recommended by the Centers for Disease Control (CDC) to help reduce the risk of associated infection(s). Furthermore, the facility failed to ensure the influenza vaccination (flu vaccine) was offered 2 of 5 residents (R7, R11) reviewed for vaccinations.

Inspectors wroteBased on record review, and interview the facility failed to provide a written notification/copy of a bed hold for 1 of 3 residents (R5) reviewed for hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide facial grooming for 1 of 2 residents (R24) reviewed for activities of daily living (ADL's) for residents who are dependent on staff for their care.

Inspectors wroteBased on interview and document review, the facility failed to offer the COVID-19 (C-19) vaccine to a resident eligible to receive the vaccine for 1 of 5 residents (R7) reviewed for immunizations.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician notification of skin injury that required treatment for 1 of 3 residents (R1) reviewed for pressure ulcers.

Inspectors wroteBased on interview and document review the facility failed to revise the care plan that addressed goals and interventions for new diagnoses of nonthrombocytopenic pupura for 1 of 1 resident (R2) who developed substantial bruising.

Inspectors wroteBased on observation, interview and document review, the facility failed to complete pressure ulcer risk assessment, failed to comprehensively assess and monitor pressure ulcers, notify physician, and follow physician orders to prevent and/or mitigate the risk of new ulcer development or deterioration for 1 of 3 residents (R1) reviewed for pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to secure a narcotic medication which was delivered without a corresponding medication order, and facility failed to investigate circumstances surrounding lost narcotic and implement action plan to prevent potential reoccurrence for 1 of 1 resident (R1) reviewed for drug diversion.

Inspectors wroteBased on interview and records review, the facility did not report allegation of drug diversion in a timely manner for 1 of 1 resident (R1) reviewed for medication management.

Inspectors wroteBased on interview and document review, the facility did not evaluate training program and re-train staff regarding allegations of verbal abuse for 1 of 1 residents (R2) reviewed for verbal abuse.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess the resident and determine safety for self-administration of medications (SAM) for 2 of 2 residents (R16 and R28) reviewed for SAM.

Inspectors wroteBased on interview and document review, the facility failed to follow up and assess a resident who requested to self-administer nitroglycerin medication for 1 of 1 resident (R16) reviewed for choices.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure bathing assistance was provided for 1 of 4 resident (R10) reviewed for activities of daily living (ADL's).

Inspectors wroteBased on observation, interview, and document review, the facility failed to consistently include all licensed nursing staff on the daily nurse staff posting. This had the potential to affect all 33 current residents, their families and visitors.

Inspectors wroteBased on observation, interview and document review, the facility failed to consistently include the facility census on the daily nurse staff posting. This had the potential to affect all 29 current residents, their families and visitors.

Inspectors wroteBased on interview and document review, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to 2 of 6 residents (R13 and R184) reviewed whose Medicare A coverage ended and then remained in the facility. In addition, the facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) for 2 of 6 residents (R13 and R183) reviewed whose Medicare A coverage ended and one resident (R13) remained in the facility and one resident (R183) transferred to another facility.