01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-09-11 | 6 | 2025-09-11 | 5 |
| Cycle 2 | 2023-11-16 | 2 | 2023-11-16 | 3 |
| Cycle 3 | 2022-08-19 | 3 | 2022-08-19 | 0 |
CMS CCN 0651422026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Lemay Avenue Health And Rehab Llc
4824 S Lemay Ave · Fort Collins, CO 80525 · Larimer County
Certified beds130CMS provider file
Recent citation rows19current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
19 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 2 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-01 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-07-23 · complaint2026-06-01 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2026-06-03 · complaint2026-06-01 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2026-06-03 · complaint2026-06-01 · HEALTHF0744Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Correction field: Deficient, Provider has date of correction · 2026-06-03 · complaint2026-06-01 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2026-06-03 · complaint2025-09-11 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-012025-09-11 · FIREK0271Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have exits that are accessible at all times.
Correction field: Deficient, Provider has date of correction · 2026-02-272025-09-11 · FIREK0293Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2026-02-272025-09-11 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2026-02-272025-09-11 · FIREK0753Severity F · widespread; potential for more than minimal harm
Miscellaneous Deficiencies
Have restrictions on the use of highly flammable decorations.
Correction field: Deficient, Provider has date of correction · 2026-02-272025-09-11 · FIREK0919Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the use of electrical equipment.
Correction field: Deficient, Provider has date of correction · 2026-02-272025-02-19 · HEALTHF0585Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Correction field: Deficient, Provider has date of correction · 2025-03-10 · complaint2023-11-16 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2023-12-062023-11-16 · FIREK0291Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2023-12-142023-11-16 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2023-12-212023-11-16 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2023-12-142022-08-19 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2022-09-132022-08-19 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure 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.
Correction field: Deficient, Provider has date of correction · 2022-09-132022-08-19 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2022-09-1703 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- No ownership disclosure row was matched in this release.
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.03per resident day
RN hours1.00per resident day
Weekend nurse hours3.65per resident day
Staff turnover92.6%CMS reported field
06 / LOCAL RECORDS
Open the Fort Collins ledger →Other published facilities nearby
Centre Avenue Health And Rehab Llc90 beds · CMS overall 5/520 citation rowsColumbine West Health And Rehab Llc100 beds · CMS overall 3/523 citation rowsCreekside Village Rehabilitation And Nursing Llc120 beds · CMS overall 1/584 citation rowsGood Samaritan Society -- Fort Collins Village64 beds · CMS overall 4/522 citation rowsPoudre Canyon Rehabilitation And Nursing, Llc83 beds · CMS overall 1/572 citation rowsRehabilitation And Nursing Center Of The Rockies106 beds · CMS overall 3/533 citation rowsStorybrook Care & Rehabilitation60 beds · CMS overall 1/552 citation rows