B+
84/100LEMAY AVENUE HEALTH AND REHAB LLC Inspection Report, Violations & Safety Grade (FORT COLLINS, Colorado)
4824 S LEMAY AVE, FORT COLLINS, Colorado 80525
Phone: 8017094358
CMS Overall:5/5
Overview & Bed Count
Certified Beds
130
Avg Residents/Day
122
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Larimer
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall5/5
Health4/5
Staffing4/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Colorado Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.01 | 0.81 | +0.19 |
| Total Nurse Hours per Resident per Day | 3.92 | 3.69 | +0.22 |
| CMS Staffing Rating | 4/5 | 3.1/5 | - |
| Nursing Staff Turnover | 50.8% | 47% | - |
Health Citation History
11 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-06-01 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2026-06-01 | 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. | D – Moderate Harm Potential |
| 2026-06-01 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2026-06-01 | Quality of Life and Care Deficiencies | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | D – Moderate Harm Potential |
| 2026-06-01 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-09-11 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-02-19 | 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. | E – Moderate Harm Potential |
| 2023-11-16 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2022-08-19 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2022-08-19 | 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. | D – Moderate Harm Potential |
| 2022-08-19 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
Fire Safety Citation History
8 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-09-11 | Miscellaneous Deficiencies | Have restrictions on the use of highly flammable decorations. | F – Moderate Harm Potential |
| 2025-09-11 | Egress Deficiencies | Have exits that are accessible at all times. | E – Moderate Harm Potential |
| 2025-09-11 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | E – Moderate Harm Potential |
| 2025-09-11 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2025-09-11 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | E – Moderate Harm Potential |
| 2023-11-16 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2023-11-16 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | D – Moderate Harm Potential |
| 2023-11-16 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
Total Penalties & Fines
$54,810
Total Fine Amount (CMS)
1
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-06-01 | Fine | $54,810 | - |
| 2026-06-01 | Payment Denial | - | 26 days starting 2026-06-27 |
Need Help Finding Safe Care?
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the FORT COLLINS area at no cost.
Find Safe, Vetted Facilities Near FORT COLLINS
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.