Deficiencies per Year
8
6
4
2
0
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 16, 2025
Visit Reason
The inspection was conducted as a health care complaint investigation to assess medication administration, nursing assessments, and medication availability at Aspen Valley Senior Living Community.
Findings
The facility failed to ensure residents received medications and treatments as ordered, did not conduct nursing assessments following changes in residents' health status, and did not have all ordered PRN medications available at all times.
Complaint Details
The visit was triggered by a health care complaint investigation. Specific complaints included medication errors and lack of nursing assessments following changes in resident health status.
Deficiencies (3)
| Description |
|---|
| The facility nurse did not ensure residents received medications and treatments as ordered by their provider, including incorrect dosages for Residents #4 and #5. |
| The facility nurse did not conduct nursing assessments when residents experienced changes in physical or mental health status, including failure to assess Resident #4 after reported changes. |
| The facility did not ensure all ordered PRN medications were available to residents at all times, with several medications missing from the medication cart for Residents #1, #4, and #5. |
Report Facts
Medication dosage error: 5
Medication dosage error: 2
Dates of unassessed condition changes: Resident #4 experienced changes on 3/29/25, 4/10/25, and 4/11/25 but was not assessed.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Oldfield | Survey Team Leader | Led the health care complaint investigation survey. |
| Jackie Gamboa | Administrator | Facility administrator named in the report header. |
Inspection Report
Life Safety
Deficiencies: 4
Jun 6, 2025
Visit Reason
The inspection was conducted as a fire life safety and sanitation licensure survey to evaluate compliance with fire and life safety codes and standards.
Findings
The facility failed to provide required documentation for a 5-year internal investigation of the fire suppression system and did not meet Life Safety Code requirements related to dry system risers testing, semi-annual UL listed hood assembly suppression testing, and fuel-fired heating system inspections.
Deficiencies (4)
| Description |
|---|
| Facility could not provide documentation of 5-year internal investigation of fire suppression system; tags on riser stated October 2024. |
| Life Safety Code requirements not met: last full flow trip testing and air leakage testing on dry system risers conducted in March 2021, which is beyond the required 3-year interval. |
| Facility could only provide 1 of 2 semi-annual UL listed hood assembly suppression testing reports; missing more recent inspections. |
| Fuel-fired heating system inspections last conducted in April 2021; deficiency also noted in December 27, 2023 Building Evaluation. |
Report Facts
Years since last full flow trip testing and air leakage testing: 4
Date of last semi-annual UL hood assembly suppression testing report: Jun 6, 2024
Date of last fuel-fired heating system inspection: Apr 1, 2021
Date of Building Evaluation identifying deficiency: Dec 27, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeremy Wilson | Survey Team Leader | Named as survey team leader for fire life safety and sanitation licensure survey. |
| Jackie Gamboa | Administrator | Facility administrator named in report header. |
Inspection Report
Original Licensing
Deficiencies: 5
Feb 6, 2025
Visit Reason
The inspection was conducted as an initial licensure survey combined with a complaint investigation at Aspen Valley Senior Living Community.
Findings
The facility was found to have multiple deficiencies including failure to update Negotiated Service Agreements to reflect residents' current health status, lack of evaluation and documentation of residents' maladaptive behaviors, incomplete as-worked schedules for administrative staff, and failure to notify the licensing agency within one business day of resident falls and injuries.
Complaint Details
The inspection included a complaint investigation component as indicated by the survey type. Specific complaints involved failure to update service agreements, behavior evaluations, and timely incident reporting.
Deficiencies (5)
| Description |
|---|
| Negotiated Service Agreements (NSAs) were not updated to reflect significant changes in health status for Residents #1 and #2. |
| The facility did not evaluate residents when they exhibited maladaptive behaviors, including pinching, striking, biting, and attention-seeking behaviors. |
| The facility did not document the times and dates of behaviors, interventions used, and their effectiveness for Residents #1 and #2. |
| The facility's as-worked schedule did not document dates and times worked by administrator, nurses, business office manager, and maintenance director. |
| The facility did not notify Licensing and Certification within one business day of Resident #1's and Resident #2's falls and related evaluations. |
Report Facts
Incident dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jackie Gamboa | Administrator | Named in relation to deficiencies regarding service agreements, behavior documentation, and administrative schedules. |
| Jenny Walker | Survey Team Leader | Led the initial licensure and complaint investigation survey. |
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