Victory Health and Rehabilitation: Unsecured Meds - MN
Inspectors were watching.
From 1:07 p.m. to 1:39 p.m. on September 5, thirteen staff members and eleven residents walked by the open cart on what the inspection report identifies only as a named hall. One resident reached out and touched items sitting on top of it. Nobody locked the cart. Nobody appeared to notice it was a problem.
When licensed practical nurse LPN-A returned to the cart at 1:39 p.m., she told inspectors she had been in another area for about thirty minutes. She acknowledged the cart was supposed to be locked while she was away, to prevent anyone from getting into the medications inside.
A second nurse, LPN-B, told inspectors the same thing that afternoon: when she leaves the cart, she is supposed to lock it.
The facility's own medication storage policy, dated 2001, states that medications and biologicals are kept in locked compartments and that only authorized personnel have access to keys. The policy has apparently been in place for more than two decades. The cart was not locked.
Three days later, when inspectors returned on September 8, the director of nursing told them it was "critical" for nurses to lock medication carts before walking away, to prevent access by unauthorized staff, residents, and visitors. The administrator called it "a basic standard of practice."
Neither offered an explanation for why it had not happened.
The inspection, a complaint investigation, found the violation in the only medication cart observed. CMS classified the harm level as minimal harm or potential for actual harm, with few residents affected.
What the classification does not capture is the specific nature of what was left accessible. Medication carts in nursing homes typically carry a range of drugs for multiple residents, including controlled substances, which are required under federal standards to be stored in separately locked compartments. The inspection report does not specify what was in this cart, or whether the resident who touched items on top of it made contact with anything beyond the cart's surface.
That detail is not in the record. What is in the record is that eleven residents passed an unlocked cart during a thirty-minute window, one of them close enough to touch it, and the nurse responsible for it was somewhere else entirely.
Victory Health and Rehabilitation is a nursing facility in Minneapolis. The inspection was conducted September 5 and 8, 2025.
The director of nursing described locking the cart as critical. The administrator described it as basic. The nurse who left it open said she knew she was supposed to lock it. By every account in the inspection report, everyone at the facility understood the rule.
The cart was still unlocked when inspectors arrived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Victory Health and Rehabilitation Center from 2025-09-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
VICTORY HEALTH AND REHABILITATION CENTER in MINNEAPOLIS, MN was cited for violations during a health inspection on September 8, 2025.
on September 5, thirteen staff members and eleven residents walked by the open cart on what the inspection report identifies only as a named hall.
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.