South Platte Rehab: Oxygen Failure Puts Resident at Risk - CO
That gap, inspectors found, put at least one resident in immediate jeopardy. Federal investigators cited the facility following a complaint inspection completed October 15, 2025, after examining what happened to Resident #2, a woman who depended on supplemental oxygen and who ended up on a portable canister with no one assigned to monitor it.
The sequence began when the facility lost power. Staff placed Resident #2 on a portable oxygen canister, which was full at the time. When power was restored, nobody switched her back to her oxygen concentrator. Nobody tracked how much oxygen remained in the canister. Nobody rounded on her specifically because she was running on a finite supply.
LPN #1, who had checked on Resident #2 at 4:45 that afternoon to take her blood pressure and talk about dinner, told inspectors the resident was not cyanotic and was not gasping at that point. She said she supposed it probably would have been her responsibility to switch the resident from the portable canister back to the concentrator. She did not say she had done it.
CNA #3 was working the day shift and had gone into Resident #2's room that morning for breakfast. The resident hadn't complained of pain or shortness of breath. CNA #3 described her as really good at using her call light when she needed something. But CNA #3 also told inspectors it was not routine to regularly check on residents who were on portable oxygen canisters. She said she did not know who should have been responsible for switching Resident #2 back to her concentrator once power came back on.
That answer, repeated in different forms by multiple staff members, was the finding.
The Director of Nursing, interviewed a second time during the inspection, acknowledged that someone should have checked on the canister. She said nurses and CNAs should have been monitoring it to make sure it didn't run out. She did not describe a system that ensured that happened. She did not name a protocol that assigned responsibility to a specific role. The portable canister had been full when the power went out. By the time inspectors were asking questions, it had not been full for some time.
Immediate jeopardy is the most serious level of harm designation available to federal inspectors. It means the facility's failure had placed, or was likely to place, a resident in a situation where serious injury, serious harm, serious impairment, or death was possible. The designation triggers an accelerated enforcement timeline and requires a facility to demonstrate it has removed the jeopardy before inspectors will lower the finding.
What the record shows is a resident who needed oxygen, a power outage that moved her to a backup supply, and a staff that had no shared understanding of who was watching the clock on that supply. LPN #1 guessed it was probably her job. CNA #3 didn't know whose job it was. The DON said someone should have done it.
Resident #2, according to the staff who saw her that day, was alert, communicative, and using her call light. She was not in distress at the moments staff described. She did not complain. She was, by every account in the inspection report, a cooperative patient who trusted that the people around her were managing what she could not manage herself, which was the oxygen flowing to her body.
She had no way to know the canister was running down. She had no way to know that the staff who passed through her room that day had each, in their own way, assumed someone else had the situation handled.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Platte Rehabilitation and Nursing LLC from 2025-10-15 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
SOUTH PLATTE REHABILITATION AND NURSING LLC in BRUSH, CO was cited for violations during a health inspection on October 15, 2025.
That gap, inspectors found, put at least one resident in immediate jeopardy.
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.