Victory Health & Rehabilitation Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and document review, the facility failed to ensure an allegation of potential abuse for 2 of 2 residents (Resident R1, Resident R2) who were involved in a resident-to-resident physical altercation, was reported immediately but no later than 2 hours to the State Agency (SA).Findings include:A Facility Reported Incident (FRI) submitted to the SA indicated on 8/29/25 at approximately 11:00 p.m. a verbal altercation between Resident R1 and Resident R2 occurred and Resident R1 allegedly struck Resident R2 in the face. The report was submitted to the SA

on 9/3/25 at 11:45 a.m.Resident R1's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R1 was cognitively intact and had no behaviors. Resident R2's modification of significant change MDS dated [DATE REDACTED], indicated Resident R2 was cognitively intact, and had verbal behaviors 1-3 days in the 7-day look-back period.Resident R2's hospital Discharge summary dated , 8/30/25 indicated a diagnosis of a dislocation of left side of jaw that was reduced, able to open but not close fully, contusion right chest wall.Prescribed oxycodone 5 mg, 1 tab every 8 hours as neededDuring an interview on 9/5/25 at 3:40 p.m., licensed practical nurse (LPN)-B stated she did not report the incident between Resident R1 and Resident R2 to the SA; she only reported it to the director of nursing (DON), but was supposed to report to the administrator, who reports to the SA. During an interview on 9/8/25 at 10:20 a.m., LPN-C stated abuse was reported in less than 24 hours and was not aware how to report to the SA but stated there was a book with instructions somewhere in the nurses' station. During an interview on 9/8/25 at 10:37 a.m., the DON stated abuse reporting was important because each resident should feel free from abuse and residents should receive high quality of care in a safe model. The DON stated abuse should be reported to the SA within 2 hours, and staff could report themselves, but should also inform the DON and administrator of abuse allegations. During an interview on 9/8/25 at 11:21 a.m., the administrator stated any staff could report abuse but should still inform the DON and administrator of abuse allegations.

The administrator stated abuse was supposed to be reported to the SA within 2 hours and was not for this incident because the incident happened over the weekend, staff were not correctly informed, and it was reported as soon as the administrator was aware of the oversight. Additionally, the facility had begun retraining staff as of 9/3/25.The Abuse Investigating and Reporting policy dated July 2017, indicated an alleged violation of abuse will be reported immediately, but not later than two hours.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Victory Health & Rehabilitation Center

512 49th Avenue North Minneapolis, MN 55430

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, interview, and record review the facility failed to ensure medications were stored and secured safely in 1 of 1 medication carts observed. Findings include:During an observation on 9/5/25 from 1:07 p.m. to 1:39 p.m., the medication cart outside the dining room on the [NAME] Hall was unlocked and unattended. During that time, thirteen staff and eleven residents walked by the unlocked cart. One of the residents touched items on top of the cart. During an observation and interview on 9/5/25 at 1:39 p.m., licensed practical nurse (LPN)-A returned to the medication cart, and stated she had been away to another area for about 30 minutes. LPN-A stated the cart was supposed to be locked to prevent others from accessing the medications in the cart. During an interview on 9/5/25 at 3:40 p.m., LPN-B stated when she leaves the medication cart, she is supposed to lock it. During interview on 9/8/25 at 10:37 a.m., the director of nursing stated it was critical for nurses to lock medication carts before they walk away from the cart to prevent access from unauthorized staff, residents, and visitors. During interview on 9/8/25 at 11:21 a.m.,

the administrator stated it was a basic standard of practice to lock the medication cart prior to walking away from the cart. The Medication Labeling and Storage policy dated 2001, indicated the facility stored medications and biologicals in locked compartments, and only authorized personnel had access to keys.

Event ID:

Facility ID:

If continuation sheet