Valley View Villa
VALLEY VIEW VILLA in FORT MORGAN, CO — inspection on December 1, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
appeared Resident #1 did not get the methadone and instead got 30 mg of oxycontin.The DON said she asked how the resident was and RN #3 said Resident #1 had no issues overnight.
The DON said she herself did not see any change in Resident #1 after the incident.
The DON said when she spoke to Resident #1, she would answer coherently and had a conversation with her.
The DON said if Resident #1 was not opioid tolerant, the medication error could have caused decreased breathing, altered consciousness, confusion and drowsiness.
The DON said the experienced nurse was supposed to stay with the new nurse during medication administration and also while they were learning new residents.
The DON said RN #3 said her nurse preceptor (RN #2) was around but not hovering over her, or watching her at the time of the incident.
The DON said the nurse preceptor (RN #2) was not watching exactly what RN #3 was doing.
The DON said after the incident, she completed one-on-one education with RN #3 and stressed the importance of following the five rights of medication administration.
The DON said she started an action plan to work on decreasing the amount of medication errors.
The DON said she did medication audits with nursing staff which involved observing staff members during medication administration.
She also completed continued education with staff.
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