Aspin Wall Residential Assisted Living LLC

A revisit survey was completed on 4/22/26 for all previous deficiencies cited on 11/26/25. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A recertification survey was completed on 11/26/25. Deficiencies were cited. Based on observation, record reviews and interviews, the facility (residence) failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 10 current member (residents).Findings include:The staff schedule was a recurring schedule that listed the administrator as scheduled to work two- 24 hour shifts on Friday and Saturday.The staff list revealed the administrator was hired on 2/12/19. The administrator' s CPR certification read the certification required renewal by 08/2025. However, the residence provided no updated certification.On 11/26/25 at 8:56 a.m., the administrator stated the posted schedule was a standard one and that sh.. Based on record review and interview, the facility (residence) failed to ensure a Colorado Adult Protective Services Data Systems (CAPS) check was performed prior to hiring, request, prior to hire and a criminal history record check conducted by the Colorado Bureau of Investigation (CBI), affecting ten current members (residents).Findings include:The personnel file for Staff #2 revealed a hire date of 10/24/22, but no evidence that the residence requested a CAPS or CBI check. The October and November 2025 staff schedule revealed Staff #2 worked the following shifts: Staff #2 worked 24 hour shifts from Sunday through Tuesday. On 11/25/25 at approximately 11:49 a.m., the administrator stated she was unaware of the requirement for CAPS and CBI checks, and did not hire Staff #2. She con.. Based on record review and interview, the facility (residence) failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 10 current members (residents). Findings include:On 11/25/25 at approximately 12:19 p.m., the residence' s involuntary discharge grievance policy was requested; however, the policy was not provided while onsite. On 11/25/25 at approximately 2:08 p.m., the administrator acknowledged she was not aware of the requirement for an involuntary discharge grievance policy that met the requirements of Chapter VII, Regulation 9.3 (A-I). The administrator acknowledged that the policy did not exist. The administrator stated she was unaware of the policy and explained that the previous owner was responsible for ensuri.. Based on records review and interviews, the facility (residence) failed to ensure member (resident) agreements were reviewed annually, affecting two of three (#2 and #3) sample residents.Findings Include:Resident #3 was admitted to the residence on 3/18/21 with a diagnosis including schizoaffective disorder and bipolar. A residency agreement, dated 3/18/21, was the only residence agreement provided on 11/25/25.On 11/26/25, at approximately 9:04 a.m., the administrator stated she was unaware residence agreements should be updated annually or amended as necessary. The administrator acknowledged the residence agreement for Resident #3, dated 3/18/21, was not updated annually or amended as necessary. The administrator further acknowledged the residence agreement for Resident #3 did not ..

A relicensure survey was completed on 11/26/25. Deficiencies were cited. Based on interview and record review, the residence failed to ensure at least one staff member was responsible for the onsite management of the residence' s infection prevention and control program, and had completed the required training, affecting 10 current residents. Findings include: On 11/25/25 at approximately 9:00 a.m., the infection con.. Based on interviews and record review, the residence failed to ensure that each staff member met the dementia training requirements in 7.9 (B), affecting 10 current residents. Findings include:Personnel files for Staff #1 and #2-#3 provided by the administrator revealed no evidence that each staff member had completed the initial four-hour dem.. Based on observation, record reviews and interviews, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting 10 current residents.Findings include:The staff schedule was a recurri.. Based on record review and interview, the residence failed to ensure a Colorado Adult Protective Services Data Systems (CAPS) check was performed prior to hiring one of three total staff (#2) who provided direct care to at-risk residents, affecting 10 current residents. Findings include:The personnel file for Staff #2 revealed a hire date of 10/2.. Based on record review and interview, the residence failed to have a visitation policy that complied with Section 25-27-104.3, C.R.S., affecting 10 current residents. (Cross-reference U0816)Findings include:On 11/25/25 at approximately 12:19 p.m., the residence' s visitation policy was requested and provided; however, the policy provide.. Based on record review and interview, the residence failed to have an involuntary discharge grievance policy that complied with Section 25-27-104.3, C.R.S., affecting 10 current residents. (Cross-reference U0812)Findings include:On 11/25/25 at approximately 12:19 p.m., the residence' s involuntary discharge grievance policy was requested; howev.. Based on record review and interview, the residence failed to request, prior to hire, a criminal history record check conducted by the Colorado Bureau of Investigation (CBI) for one of three sample staff (#2) affecting 10 current residents. Findings include: Review of personnel records revealed Staff #2 was hired on 10/24/22. However, there w.. Based on records review and interviews, the residence failed to ensure resident agreements were reviewed annually, affecting two of three (#2 and #3) sample residents.Findings Include:Resident #3 was admitted to the residence on 3/18/21 with a diagnosis including schizoaffective disorder and bipolar. A residency agreement, dated 3/18/21, was .. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.9.1 The assisted living residence shall develop and at least annually rev..

A revisit survey was completed on 1/30/24 for all previous deficiencies cited on 7/18/23. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A licensure complaint, prompted by #CO32770, was completed on 7/18/23. Deficiencies were cited. Based on interview and record review, the residence failed to ensure each personnel file included first aid and cardiopulmonary resuscitation (CPR) certification, affecting nine current residents. (Cross-reference Q732, Q734).Findings include:On 7/18/23 at approximately 8:00 a.m., first aid and CPR certifications were requested for Staff #1, #3 and the administrator. However, the administrator was unable to locate the certifications for Staff #1 as required. She provided a certification that expired on 6/1/23 for Staff #1.On 7/18/23 at 10:45 a.m., the administrator stated she could not located the certification for Staff #1 and only had his expired certifications. She stated the staff.. Based on interview and record review, the residence failed to have a roster of current residents that included their emergency contact information, along with a residence diagram showing room locations, affecting nine current residents. Findings include:On 7/18/23 at approximately 8:00 a.m. the resident roster was requested and provided. However, the resident roster did not include the residents' emergency contact information, along with a residence diagram showing room locations.On 7/18/23 at 10:45 a.m., the administrator stated she was not aware that residents' emergency contact information or a residence diagram showing room locations was required to be included with the .. Based on observation and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid or CPR (cardiopulmonary resuscitation) that was readily available to staff at all times, affecting nine current residents. (Cross-reference Q732, Q734)Findings include: During an environmental tour on 7/18/23 there was a list of all staff who have current certification in first aid or CPR placed in a visible place, however, the list was inaccurate. The list read that all staff at the residence were CPR and first aid certified. However, record review revealed the CPR/first aid certification for the administrator had expired on 6/1/23 and the.. Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization, affecting nine current residents. (Cross-reference Q664, Q732, Q736)Findings include:1. References and residence policya. According to Mayo Clinic, "Cardiopulmonary resuscitation (CPR) is a lifesaving technique that' s useful in many emergencies, such as a heart attack or near drowning, in which someone' s breathing or heartbeat has stopped. The American Heart Association recommends starting CPR with hard and fast chest compressi.. Based on record review and interview, the residence failed to have at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization, affecting nine current residents. (Cross-reference Q664, Q734, Q736)Findings include:1. Residence policyThe residence' s undated First Aid policy, read in part, the residence had at least one staff member onsite at all times who had current certification in first aid from a nationally recognized organization. 2. Record Reviewa. Staff first aid certificationsThe following staff received first aid certifications as follows:Staff #1 on 5/4/21Staff #3 on 4/5/22.The administrator on 5/4/21.b. Staffi..