Report
TheVardellReport
High Plains Post Acute LLC
Skilled nursing facility and nursing facility
1209 W Abriendo Ave
Pueblo, CO 81004
Report
← High Plains Post Acute LLC, free profile
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The Vardell Report.High Plains Post Acute LLC
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Pueblo, CO
- Record Period
- 2022–2025
- Source Documents
- 7
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 5 inspections from May 2022 to August 2025, state surveyors documented 33 findings at High Plains Post Acute LLC; 33 have a recorded correction; CMS lists 3 enforcement actions in the window.
- Inspections
- 5
- 2022–2025, complaint and standard
- Findings
- 33
- Deficiencies cited by state inspectors
- Corrected
- 33
- Of 33 findings, with a recorded correction date
- Penalties
- 3
- 3 fines; payment not published
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2022 | 1 | 8 | 0 |
| 2023 | 1 | 13 | 3 |
| 2024 | 1 | 1 | 1 |
| 2025 | 2 | 11 | 2 |
| 2026 | 0 | 0 | 0 |
What the Record Shows
- 33 of 33 findings have a recorded correction date.
- CMS lists 3 enforcement actions in the window: 3 fines totaling $57,734, their payment not published.
- 3 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, February 27, 2025, recorded 5 findings (most serious: Level G).
Report at a Glance
- Facility
- High Plains Post Acute LLC
- Address
- 1209 W Abriendo Ave, Pueblo, CO 81004
- CMS Certification Number
- 065355
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 59
- Ownership
- For profit - Limited Liability company
- Record Window
- May 10, 2022 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2025
Complaint investigation
6 findings
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Sep 8, 2025
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Sep 8, 2025
- F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Sep 8, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Sep 8, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Sep 8, 2025
- F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Level BPotential for minimal harmCorrected Sep 8, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
5 findings
The same visit included a complaint investigation.
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Mar 26, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
- F758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
- F880Provide and implement an infection prevention and control program.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
- F881Implement a program that monitors antibiotic use.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
Enforcement Action
Civil money penalty, $33,248 imposed February 27, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 27, 2025, the nearest before the penalty date.
Enforcement Action
Civil money penalty, $12,438 imposed August 11, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 27, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level GActual harmCorrected Apr 26, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
13 findings
- F760Ensure that residents are free from significant medication errors.Level JImmediate jeopardyCorrected Sep 7, 2023
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level GActual harmCorrected Sep 7, 2023
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level GActual harmCorrected Sep 7, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level FNo actual harm, potential for moreCorrected Sep 7, 2023
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Level FNo actual harm, potential for moreCorrected Sep 7, 2023
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Level FNo actual harm, potential for moreCorrected Sep 7, 2023
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Level ENo actual harm, potential for moreCorrected Sep 7, 2023
- F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Level ENo actual harm, potential for moreCorrected Sep 7, 2023
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level ENo actual harm, potential for moreCorrected Sep 7, 2023
- F554Allow residents to self-administer drugs if determined clinically appropriate.Level DNo actual harm, potential for moreCorrected Sep 7, 2023
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Sep 7, 2023
- F679Provide activities to meet all resident's needs.Level DNo actual harm, potential for moreCorrected Sep 7, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Level DNo actual harm, potential for moreCorrected Sep 7, 2023
Enforcement Action
Civil money penalty, $12,048 imposed April 1, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of August 14, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2022
Standard health inspection
8 findings
- F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Jun 20, 2022
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Level DNo actual harm, potential for moreCorrected Jun 20, 2022
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 20, 2022
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Level DNo actual harm, potential for moreCorrected Jun 20, 2022
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Level DNo actual harm, potential for moreCorrected Jun 20, 2022
- F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Level DNo actual harm, potential for moreCorrected Jun 20, 2022
- F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.Level DNo actual harm, potential for moreCorrected Jun 20, 2022
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Level DNo actual harm, potential for moreCorrected Jun 20, 2022
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Accident Hazards and Supervision, Cited in Four Inspections
Inspectors cited F689 in August 2023, April 2024, February 2025 and August 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242525F689 across all 5 inspections, oldest to newest - 2
Provide activities to meet all resident's needs, Cited in Two Inspections
Inspectors cited F679 in August 2023 and August 2025. The agency describes it this way: Provide activities to meet all resident's needs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242525F679 across all 5 inspections, oldest to newest - 3
Mobility and Range of Motion, Cited in Two Inspections
Inspectors cited F688 in May 2022 and August 2023. This citation covers care that keeps or improves a resident’s movement and mobility. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242525F688 across all 5 inspections, oldest to newest - 4
Respiratory Care, Cited in Two Inspections
Inspectors cited F695 in August 2023 and August 2025. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
2223242525F695 across all 5 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in four inspections, most seriously at level G.
- 02
What changed after F679 was cited, and how do you check it now?
Provide activities to meet all resident's needs: cited in two inspections, most seriously at level E.
- 03
What do you do to keep residents moving, and who provides range-of-motion care?
Mobility and Range of Motion: cited in two inspections, most seriously at level G.
- 04
Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?
Respiratory Care: cited in two inspections, most seriously at level D.
- 05
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
- 06
What led to the 2025 fine, and has it been paid?
A $12,438 civil money penalty was imposed August 11, 2025. CMS publishes the fine, not whether it has been paid. The record holds three enforcement actions in the window.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Colorado state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Colorado state survey agency
Inspection May 10, 2022 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Colorado state survey agency
Inspection Aug 14, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Colorado state survey agency
Inspection Apr 1, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Colorado state survey agency
Inspection Feb 27, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Colorado state survey agency
Inspection Aug 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Penalties, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 065355
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowMay 10, 2022 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before May 2022 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
- Whether fines were paid
- CMS publishes the fines imposed, not whether or when they were paid.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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