Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
123% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 27, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding failure to ensure activities of daily living, specifically shaving, were completed for a resident.
Complaint Details
The investigation was complaint-related concerning failure to assist resident R22 with shaving. The complaint was substantiated as staff signed off on shaving tasks that were not completed, and the resident was observed with several days' growth of facial hair.
Findings
The facility failed to ensure that resident R22 received assistance with shaving as required by his care plan and treatment records. Staff signed off on shaving tasks as completed despite the resident having visible facial hair and stating a preference to be clean shaven.
Deficiencies (1)
F 0676: The facility failed to ensure residents did not lose the ability to perform activities of daily living unless medically justified. Resident R22 was not assisted with shaving as required, despite documentation indicating shaving was completed.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| nursing assistant (NA)-A | Stated responsibilities for assisting residents with shaving and signing off task completion. | |
| registered nurse (RN)-A | Confirmed task sign-off issues and explained refusal documentation. | |
| director of nursing (DON) | Stated expectations for task completion and documentation, and noted possible issue with resident's shaver. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 27, 2025
Visit Reason
The inspection was conducted to investigate complaints related to informed consent for psychotropic medication, activities of daily living assistance, wound assessment and monitoring, and infection prevention and control practices.
Complaint Details
The investigation was complaint-driven, focusing on issues of informed consent for psychotropic medication, grooming assistance, wound care assessment, and infection control practices. The complaints were substantiated with findings of minimal harm affecting a few residents.
Findings
The facility failed to obtain informed consent for psychotropic medication for one resident, did not ensure proper assistance with shaving for one resident, failed to accurately assess and report wound deterioration for one resident, and did not consistently perform hand hygiene or follow enhanced barrier precautions during personal and wound care.
Deficiencies (4)
F 0552: The facility failed to inform and obtain consent for psychotropic medication use for 1 of 5 residents reviewed.
F 0676: The facility failed to ensure activities of daily living, including shaving, were completed for 1 of 1 resident reviewed.
F 0684: The facility failed to ensure wounds were accurately assessed and reported when deteriorating for 1 of 3 residents reviewed for wound assessment.
F 0880: The facility failed to ensure hand hygiene was performed and enhanced barrier precautions were followed for 1 of 3 residents observed during personal and wound cares.
Report Facts
Residents reviewed for psychotropic medication consent: 5
Residents reviewed for grooming: 1
Residents reviewed for wound assessment: 3
Residents observed for infection control: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-A | Licensed Practical Nurse | Interviewed regarding informed consent and wound care observations. |
| DON | Director of Nursing | Interviewed regarding expectations for informed consent, grooming, and wound care. |
| RN-C | Registered Nurse | Observed performing wound care with missed hand hygiene and PPE use. |
| NA-E | Nursing Assistant | Observed performing personal cares with missed hand hygiene. |
| RN-D | Nurse Lead and Infection Preventionist | Interviewed regarding infection control expectations. |
Inspection Report
Routine
Census: 72
Deficiencies: 6
Date: Mar 13, 2025
Visit Reason
The Minnesota Department of Health conducted a survey to evaluate and assess compliance with state licensing statutes for Friendship Village Bloomington.
Findings
The licensee was found to be in substantial compliance but had several violations including food service violations, failure to provide required emergency relocation notices, incomplete background studies for employees, incomplete dementia care training, incomplete service plans, and failure to ensure appropriate care related to a resident's assistive device (side rail).
Deficiencies (6)
Failed to ensure food was prepared and served according to the Minnesota Food Code, resulting in a level two violation at widespread scope.
Failed to provide a written notice with required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care for one resident.
Failed to ensure background studies were submitted and clearance received for two employees affiliated with the correct health facility identification.
Failed to ensure required eight hours of dementia care training was completed for one direct-care employee within 160 hours of employment.
Failed to ensure the service plan included all required content such as identification of services including blood glucose monitoring and compression stockings, and identification of staff providing services for one resident.
Failed to provide care and services according to accepted health care standards related to a resident's assistive device (side rail), including lack of referral to Consumer Product Safety Commission for bedrail recall information and incomplete risk assessment documentation.
Report Facts
Residents present: 72
Background study correction timeframe: 2
Emergency relocation correction timeframe: 21
Dementia care training correction timeframe: 21
Service plan correction timeframe: 21
Side rail care correction timeframe: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse | Named in findings related to background study deficiency, emergency relocation notice deficiency, dementia care training deficiency, service plan deficiency, and side rail care deficiency. |
| ULP-B | Unlicensed Personnel | Named in findings related to background study deficiency and dementia care training deficiency. |
| LALD-C | Licensed Assisted Living Director | Acknowledged background study deficiencies for RN-A and ULP-B. |
| RN-F | Registered Nurse | Observed side rail secured to resident's bed. |
| LPN-D | Licensed Practical Nurse | Observed administering insulin and blood glucose check for resident R2. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 2, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to implement care plans for monitoring bruising and ensuring safe transfer interventions for residents.
Complaint Details
The investigation was complaint-driven, focusing on allegations of inadequate monitoring of bruising and improper transfer techniques. The complaint was substantiated with evidence of care plan noncompliance and unsafe transfer practices.
Findings
The facility failed to implement care plans for monitoring and documenting bruising for two residents and did not consistently follow transfer interventions for one resident, posing potential harm.
Deficiencies (1)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, including timely and measurable actions for monitoring bruising and safe transfers.
Report Facts
Bruise measurements: 4.5
Bruise measurements: 4
Bruise measurements: 3.8
Bruise measurements: 3.5
Bruise measurements: 3.8
Bruise measurements: 3
Bruise measurements: 2.4
Bruise measurements: 2.6
Bruise measurement: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-A | Nursing Assistant | Observed transferring resident R18 without gait belt or assistance, contrary to care plan |
| RN-A | Registered Nurse | Observed assisting with transfer of resident R18 and confirmed non-use of gait belt |
| LPN-A | Licensed Practical Nurse, Unit Manager | Confirmed staff were to use gait belt and two-person assistance for transfers as per care plan |
| NA-G | Nursing Assistant | Described transfer method for resident R18 involving one-person lift without gait belt |
| DON | Director of Nursing | Confirmed discrepancies in transfer methods and potential for injury to resident R18 |
| Administrator | Indicated all residents were to receive care according to individualized care plans and participated in interviews |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: May 2, 2024
Visit Reason
The inspection was conducted due to complaints and concerns regarding failure to recognize, report, and investigate injuries of unknown origin, inadequate notification of transfers to the Office of Ombudsman, failure to implement care plans for bruising and pressure ulcer risk, inadequate supervision during transfers, and improper use of psychotropic medications.
Complaint Details
The complaint investigation focused on failure to report and investigate injuries of unknown origin, failure to notify the Ombudsman of transfers, failure to implement care plans for bruising and pressure ulcer prevention, inadequate supervision during transfers, and improper use of psychotropic medications. Immediate jeopardy was identified due to failure to investigate injuries of unknown origin but was removed after corrective actions.
Findings
The facility failed to timely report and investigate injuries of unknown origin for multiple residents, failed to notify the Office of Ombudsman of resident transfers, failed to implement care plans for monitoring bruises and pressure ulcer prevention, failed to provide adequate supervision during resident transfers, and failed to provide nonpharmacological interventions prior to administering antianxiety medications. Immediate jeopardy was identified but removed after corrective actions.
Deficiencies (9)
F0609: The facility failed to timely report suspected abuse or injuries of unknown origin for 4 residents with suspicious bruises and failed to thoroughly investigate these injuries.
F0610: The facility failed to thoroughly investigate injuries of unknown origin for 4 residents, constituting an immediate jeopardy situation that was later removed.
F0623: The facility failed to notify the Office of Ombudsman of 12 facility-initiated resident transfers as required.
F0656: The facility failed to develop and implement complete care plans with measurable actions for monitoring and documenting bruising and ensuring safe transfers for residents.
F0684: The facility failed to provide appropriate treatment and monitoring of bruises and failed to accurately document bruise location and color for residents reviewed.
F0686: The facility failed to provide timely assistance with repositioning to minimize pressure ulcer risk for a resident in accordance with the individualized care plan.
F0689: The facility failed to provide adequate supervision during transfers and failed to provide timely assistance devices for a resident at risk of injury.
F0690: The facility failed to provide timely assistance with incontinence cares for a resident in accordance with the individualized care plan.
F0758: The facility failed to provide nonpharmacological interventions prior to administering as needed antianxiety medications for a resident.
Report Facts
Bruise size: 7
Bruise size: 10
Bruise size: 5.5
Bruise size: 4.5
Bruise size: 3.8
Bruise size: 3.8
Bruise size: 2.4
Medication dose: 0.5
Medication dose: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-A | Licensed Practical Nurse | Responsible for investigating bruises and reporting to Nurse Practitioner; involved in care and transfer of R18 |
| RN-A | Registered Nurse | Confirmed facial bruise was suspicious and staff should have reported it; supervised transfers |
| NA-G | Nursing Assistant | Assisted with transfers of R18 using one-arm under shoulder/neck and one under buttocks method |
| LPN-B | Licensed Practical Nurse | Notified about bruises and involved in assessments |
| RN-C | Registered Nurse | Assessed bruises and completed incident reports |
| DON | Director of Nursing | Oversaw investigations and confirmed failures in reporting and supervision |
| Administrator | Facility Administrator | Acknowledged failures in reporting and investigations; involved in corrective actions |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, meal service, care planning, hospice collaboration, and sanitation in the nursing facility.
Findings
The facility was found deficient in providing a dignified dining experience by failing to serve meals timely to residents at the same table, delayed baseline care planning for a newly admitted resident, ineffective collaboration with hospice services resulting in missed medication, and failure to maintain proper dishwasher temperatures for sanitation.
Deficiencies (5)
F 0550: The facility failed to provide a dignified dining experience by not serving meals timely to residents at the same table, affecting 25 residents on the Maple Unit.
F 0655: The facility failed to ensure a baseline care plan was reviewed and provided timely for 1 resident, delaying person-centered care planning.
F 0684: The facility failed to ensure effective collaboration with a contracted hospice organization, affecting 2 residents, resulting in lack of hospice visit calendars and notes.
F 0812: The facility failed to ensure the high temperature dishwasher reached proper temperatures for sanitation, affecting all 61 residents.
F 0849: The contracted hospice agency failed to reorder a hospice covered medication timely for 1 resident, resulting in 14 days without medication.
Report Facts
Residents affected: 25
Residents affected: 61
Days medication missed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-E | Hospice RN Case Manager | Confirmed lack of hospice visit calendar and medication refill issues |
| LPN-A | Licensed Practical Nurse | Observed resident agitation during meal service and commented on hospice visit calendar expectations |
| DON | Director of Nursing | Provided expectations on baseline care plan timing and hospice communication |
| KC | Kitchen Coach | Confirmed dishwasher temperature deficiencies |
| LPN-B | Licensed Practical Nurse | Described medication reorder process and concerns about missed medication |
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