Valley View Manor: Unauthorized Wound Treatments - MN
The detail emerged during a November 2025 complaint inspection at the 200 East Ninth Avenue facility, when a licensed practical nurse identified in records as LPN-B was observed changing the dressing on a right leg wound belonging to a resident identified as R7. The wound had sutures. It was not healing.
LPN-B cleansed the wound with a skin prep wipe, applied bacitracin ointment, and put on a new foam dressing. Then she acknowledged to inspectors that R7 did not have a physician order for any of it — and that she had been doing it for some time.
She said she would contact the physician to report the remaining sutures and get an order.
R7 was not the only resident involved. The inspection found that a second resident, identified as R5, had also received treatment applied without a physician order. The report does not describe R5's condition in detail, but the director of nursing confirmed that neither R5 nor R7's treatments were part of the facility's standing orders.
The director of nursing, interviewed the morning of November 19, was direct about what should have happened. She said it is standard practice for a nurse to contact a physician and obtain an order before beginning any treatment, and that her expectation was for licensed staff to ensure this was done before initiating anything.
It had not been done. For some time.
The facility's own medication and treatment policy, dated June 30, 2024, states that medications shall be administered only upon the written order of a licensed and authorized prescriber. A separate skin care policy, undated, states that skin treatments will be performed per medical doctor order.
Neither policy had been followed in R7's case. How long the treatments had been going on without authorization, the inspection report does not say. LPN-B's phrase, offered to inspectors during the dressing change, was simply that she had been applying it "for some time."
What the report does say is that the wound was still there, still sutured, still not healing, on the day inspectors walked in.
The violation was cited at a level of minimal harm or potential for actual harm, affecting a few residents. That classification sits near the lower end of the federal harm scale, but the underlying facts describe something more unsettling than the category implies: a nurse administering ongoing wound treatment, including a topical antibiotic, to a resident with an open, sutured, non-healing wound, without a physician ever signing off on the approach.
Bacitracin is a common antibiotic ointment, available over the counter, and broadly considered low-risk. But the concern the inspection captures is not about whether bacitracin is dangerous in isolation. It is about a wound that was not healing, a treatment being applied to it repeatedly, and a physician who did not know either of those things was happening because nobody had called.
LPN-B said she would make that call. The inspection report does not say whether she did, or what the physician found when they finally reviewed R7's leg.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley View Manor Hcc from 2025-11-19 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 20, 2026 · Our methodology
Valley View Manor Hcc in LAMBERTON, MN was cited for violations during a health inspection on November 19, 2025.
LPN-B cleansed the wound with a skin prep wipe, applied bacitracin ointment, and put on a new foam dressing.
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.