High Plains Post Acute: Oxygen Tank Safety Failures - CO
That was the finding when federal inspectors visited High Plains Post Acute LLC on West Abriendo Avenue in August 2025, following a complaint. The deficiency was tagged at the lowest level of harm, meaning inspectors determined no resident had been seriously hurt yet. But the word "yet" carries weight when the concern is oxygen.
The Director of Nursing acknowledged during the inspection that when portable oxygen tanks were filled, staff were supposed to wear an apron, gloves, and a face shield. The protective equipment existed as a requirement. It was not being followed.
Beyond the PPE failure, the facility had no documented process for keeping track of how much oxygen remained in tanks used by residents. There was no record of tanks being checked at the start of shifts. There was no schedule for checking them every two hours. If a tank was running low, no written protocol told staff what to do. If a tank was empty, there was no chain of notification. A charge nurse might find out. Or might not.
Oxygen-dependent residents rely on those tanks to breathe. A tank that goes unmonitored and runs empty is not an inconvenience. For someone whose lungs cannot compensate on their own, it is a medical emergency.
The facility moved to correct the problems before the inspection concluded. On August 7, four days before the inspection date recorded on the report, the Director of Nursing provided inspectors with a notebook containing an audit log. The log listed all residents with active oxygen orders. It established that oxygen tanks would be checked at the start of every shift and again every two hours throughout the day. If a tank fell below a quarter full, staff were to refill it immediately. If a tank was found completely empty, the charge nurse was to be notified right away.
Whether those steps were already in place before the complaint was filed, or whether the complaint itself prompted the facility to scramble toward a solution, the inspection report does not say.
What the report does say is that, at the time inspectors were looking, the new process was documented in a notebook. A notebook is a start. Whether the checks are actually happening, and whether staff are wearing the apron and gloves and face shield when they refill the tanks, is a question that will depend on follow-through that inspectors cannot watch around the clock.
High Plains Post Acute is a post-acute and rehabilitation facility, the kind of place where residents often arrive after hospitalizations, sometimes fragile, sometimes on supplemental oxygen because their bodies have not recovered enough to sustain adequate oxygen levels on their own. Those are the residents whose tanks were going unchecked.
The inspection was a complaint survey, meaning someone, whether a resident, a family member, or a staff member, contacted authorities with a concern before inspectors arrived. The report does not identify who filed the complaint or what specifically they reported witnessing.
The deficiency was cited under a tag carrying a finding of minimal harm or potential for actual harm, affecting few residents. In the language of federal nursing home inspections, that is the lower end of the severity scale. It does not mean the underlying problem was trivial. It means inspectors concluded that, so far, no one had been seriously injured because of it.
The gap between "so far" and "eventually" is sometimes very small.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for High Plains Post Acute LLC from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 27, 2026 · Our methodology
HIGH PLAINS POST ACUTE LLC in PUEBLO, CO was cited for violations during a health inspection on August 11, 2025.
That was the finding when federal inspectors visited High Plains Post Acute LLC on West Abriendo Avenue in August 2025, following a complaint.
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.