Victory Health & Rehab: Abuse Report Delayed 5 Days - MN
The punch landed at approximately 11:00 p.m. on August 29, 2025. By August 30, the victim, identified in inspection records only as Resident 2, was at a hospital. The discharge summary listed a dislocated left jaw that had been reduced but could not close fully, along with a contusion to the right chest wall. Doctors prescribed oxycodone for the pain.
The State Agency was not notified until September 3, at 11:45 in the morning. That is five days, give or take a few hours. The facility's own abuse reporting policy, written in July 2017, sets the deadline at two hours.
The licensed practical nurse who was working when the altercation occurred, identified in inspection records as LPN-B, told inspectors on September 5 that she had not reported the incident to the State Agency at all. She reported it to the director of nursing. She acknowledged she was supposed to report to the administrator, who then reports to the state.
A second nurse, LPN-C, told inspectors on September 8 that abuse had been reported in less than 24 hours — an account that does not match the facility's own records — and said she was not aware of how to report to the State Agency. She mentioned there was a book somewhere in the nurses' station with instructions.
Somewhere in the nurses' station. With instructions.
The director of nursing, interviewed the same morning, said abuse should be reported to the State Agency within two hours and that any staff member could file the report themselves, while also informing the DON and administrator. The director said each resident should feel free from abuse and receive high quality of care in a safe environment.
The administrator's explanation arrived twenty minutes later. The incident happened over the weekend. Staff were not correctly informed. The report went out as soon as the administrator became aware of the oversight. Retraining had already begun, as of September 3, the same day the state was finally notified.
What the inspection report does not resolve is the gap between those accounts and what actually happened in the hours after the punch. LPN-B knew. She told her supervisor. The director of nursing knew. And for five days, the State Agency did not.
Resident 1, who threw the punch, was described in quarterly assessment records as cognitively intact with no documented behavioral issues. Resident 2, who took it, was also cognitively intact, though assessment records noted verbal behaviors on one to three days in the week before the incident.
The altercation began as a verbal dispute before it turned physical. What was said, who was present, and how long it took staff to intervene are not detailed in the inspection report.
What is detailed is the injury. A dislocated jaw is not a minor outcome. The joint that connects the lower jaw to the skull had been forced out of position with enough force to require medical reduction, and even after treatment, Resident 2 could open their mouth but not fully close it. The contusion on the right chest wall suggests the blow, or the fall, or both, involved more than a single point of contact. Oxycodone is not prescribed for discomfort. It is prescribed for pain that cannot be managed another way.
The two-hour reporting window exists for a reason. When a resident is harmed by another person inside a facility, the state needs to know quickly, so it can determine whether other residents are at risk, whether the investigation is being handled correctly, and whether the person who caused the harm is still in a position to cause more. A five-day delay is not a paperwork problem. It is a five-day window during which regulators had no idea a resident had been hospitalized with a dislocated jaw after being struck by another resident in their care.
The administrator told inspectors the delay happened because it was a weekend and staff were not correctly informed. That framing treats the failure as a scheduling problem and a training gap. But LPN-B was not confused about whether something serious had happened. She reported it, immediately, to her supervisor. The question the inspection report leaves open is what the director of nursing did with that information between the night of August 29 and the morning of September 3.
The inspection was a complaint survey, meaning someone contacted regulators before the facility filed its own report. The complaint was received and inspectors arrived on September 8, five days after the facility finally submitted the incident report and ten days after the punch itself.
By that point, Resident 2 had been discharged from the hospital and returned, presumably, to the same building where the assault occurred.
The deficiency was cited at a level of minimal harm or potential for actual harm, the lower end of the federal harm scale. That classification reflects the nature of the specific violation, which was the reporting delay, not the assault itself. The physical harm to Resident 2 was real and documented. The classification does not mean the jaw healed before anyone noticed.
Victory Health & Rehabilitation Center sits at 512 49th Avenue North in Minneapolis. The inspection was completed September 8, 2025.
Resident 2 went home from the hospital able to open their mouth but not fully close it, prescribed a narcotic painkiller, and the state learned about it five days after it happened because, according to the administrator, it was a weekend.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Victory Health & Rehabilitation Center from 2025-09-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 29, 2026 · Our methodology
Victory Health & Rehabilitation Center in MINNEAPOLIS, MN was cited for abuse-related violations during a health inspection on September 8, 2025.
The punch landed at approximately 11:00 p.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.