Lemay Avenue Health and Rehab LLC
4824 S Lemay Ave, Fort Collins, CO 80525 · All homes in Fort Collins
Lemay Avenue Health and Rehab LLC, a 130-bed for profit - corporation nursing facility in Fort Collins, CO, holds a 5-star CMS overall rating - well above the 3.0-star national average, with nurse staffing above the national norm. 1 inspection finding reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 9704821584
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- 5 / 5
- Much above average · CMS overall · nat'l 3.0
- 4.40
- Above average · nurse hrs/day · nat'l 3.89
- 7
- Inspection findings · 1 serious
- $7K
- Federal penalties (1)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 065142
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 130
- Residents
- 118
- In Hospital
- No
- County
- Larimer
- Last Inspection
- Sep 11, 2025
Staffing Data
How the 4.40 total nursing hours per resident-day are staffed:
- RN Hours
- 1.27 (nat'l avg: 0.68)
- LPN Hours
- 0.43
- CNA Hours
- 2.70
- Total Nursing Hours
- 4.40 (nat'l avg: 3.89)
- PT Hours
- 0.09
- Nursing Turnover
- 46.9%
- RN Turnover
- 18.4%
What the CMS Record Reveals About Lemay Avenue Health and Rehab LLC
Lemay Avenue Health and Rehab LLC operates 130 certified beds in Fort Collins, CO with approximately 118 residents currently in care, and carries a CMS overall rating of 5 out of 5 stars (health inspection 5★ · staffing 5★ · quality 4★).
The inspection file contains 7 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $7K against this provider. Per resident day, this facility reports 4.40 total nursing hours (national average 3.89) and 1.27 RN hours.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Lemay Avenue Health and Rehab LLC falls into a category where comparative context matters. Reported nursing turnover at this facility is 46.9%, within a range generally associated with stable care teams.
Why sub-scores and the CMS methodology matter
The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results, staffing levels, and quality measures. Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. The staffing metric in particular is the one most strongly tied to resident outcomes in peer-reviewed literature.
For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (7 most recent)
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Oct 1, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Mar 10, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 6, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 27, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Sep 17, 2022
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.
Category: Pharmacy Service Deficiencies
Corrected: Sep 13, 2022
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Sep 13, 2022
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 20.4% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.8% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 5.8% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 29.6% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 4.2% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 18.7% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 1.9% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 2.7% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 1.8% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 99.7% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 15.9% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 20.9% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 95.2% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 92.0% | No |
Penalty History 1 penalties totaling $7K
| Date | Type | Amount |
|---|---|---|
| Jul 26, 2023 | Fine | $7K |
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Understanding Nursing Home Data
Frequently Asked Questions
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What quality measures are tracked for Lemay Avenue Health and Rehab LLC?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
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