Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lemay Avenue Health And Rehab Llc during CMS and state inspections, most recent first.
Failure to provide adequate supervision and person-centered fall prevention led to repeated falls for two residents. One resident with stroke-related weakness, anxiety, and worsening cognitive impairment repeatedly attempted self-transfers to the bathroom, was not consistently supported with toileting assistance or purposeful rounding, and sustained a head injury with intracranial bleeding. Another resident with Alzheimer's disease, poor memory, and impulsive behavior had multiple unwitnessed falls, including one that resulted in a right elbow fracture, while staff did not update the fall care plan or consistently provide the cueing and supervision identified in the plan.
Failure to Prevent Recurring UTIs: A resident with a history of UTI, sepsis, stroke-related weakness, and diabetes had repeated urinary infections while needing extensive help with toileting and hygiene. The resident and family reported delayed response to UTI symptoms and episodes of being left in wet or soiled clothing, and records showed a care plan for incontinence and UTI monitoring but no person-centered interventions to prevent recurrence. Notes documented positive urine cultures, dysuria, vomiting, sepsis screening, and hospitalization for severe sepsis due to UTI with ESBL and E. coli. Staff and the DON acknowledged an increase in UTIs and that incontinence care had not been audited.
The facility failed to ensure oxygen therapy was provided as ordered for two residents. One resident with CHF and chronic respiratory failure had a documented episode where a CNA transferred her to a portable tank that was empty, and her O2 saturation dropped to 50%; the record also lacked documentation showing she was returned to the ordered oxygen rate. Another resident with chronic respiratory failure and dementia had an order for continuous oxygen at 4 L, but observation showed the portable tank indicator on the last red light, which staff confirmed meant the tank was empty, and the care plan lacked key oxygen details.
Failure to Address Dementia-Related Aggression and Wandering: Two residents with dementia had documented aggressive and disruptive behaviors toward others, including scratching, hitting, kicking, grabbing, and entering other residents’ rooms. One resident with severe dementia and a history of aggression repeatedly acted out in dining and common areas, while another resident with severe dementia and wandering behaviors was observed yelling during care and roaming into other residents’ rooms without staff intervention or meaningful activity engagement.
A resident with impaired vision, diabetes, HTN, and HF was prescribed valacyclovir for exposure to keratoconjunctivitis, but the med was not administered because the pharmacy would not supply it due to lack of insurance coverage. The record showed the resident also had keratoconjunctivitis and keratitis in both eyes, and nursing notes documented that hospice would not cover the eye meds. The facility did not document informing the eye doctor that the resident was not receiving valacyclovir, and there was no documentation of consultation with the medical director or PCP for an alternative treatment when the prescriber could not be reached.
The facility failed to maintain infection control practices when a CNA used a vital signs machine in a COVID-19 positive room without disinfecting it before taking it to another resident, and another CNA took vital signs for four residents without disinfecting the machine between uses. A housekeeper also exited a COVID-19 positive room wearing full PPE and carried an open trash bag into the hallway before doffing PPE and tying the bag closed outside the room.
The facility failed to promptly resolve grievances for three residents, who reported excessive wait times for call light responses, leading to incidents of incontinence and a fall. Grievance reports lacked documentation of resolution or satisfaction, and staff interviews confirmed call lights were sometimes turned off without addressing residents' needs.
Failure to Provide Adequate Supervision and Person-Centered Fall Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and fall prevention interventions for two residents who experienced repeated falls with injury. Resident #5 had diagnoses including hemiplegia/hemiparesis following stroke, anxiety, overactive bladder, and cognitive communication deficit. The resident required partial to moderate assistance with toileting and transfers, later developed severe cognitive impairment, and had a history of falls. The resident was noted in late December 2025 to be increasingly anxious, yelling out, requesting to use the bathroom, and attempting to self-transfer without staff assistance. Resident #5 fell on 2/4/26 while attempting to self-transfer to use the bathroom, but the fall care plan was not reviewed after that fall to determine whether the interventions remained appropriate. The record also showed the resident had been added to purposeful rounding because of increased anxiety, calling out, and falling out of bed, but purposeful rounding was not included in the fall care plan. On 2/16/26, the resident fell again while attempting to self-transfer to the bathroom and sustained a laceration above the left eye and a brain injury. The investigation documented that a CNA assisted the resident into a wheelchair for breakfast, did not offer toileting assistance, and left the room; the resident then used the call light and was found on the bathroom floor after attempting to get there before staff returned. Staff interviews showed the CNA did not know the resident was on a personalized toileting schedule, and RN and CNA staff gave inconsistent descriptions of the purposeful rounding program and the resident-specific toileting interventions. Resident #15 had diagnoses including Alzheimer's disease, contractures of the right hand and fingers, a history of falls, weakness, poor memory, poor decision-making, and disorganized thinking. The resident had repeated unwitnessed falls on 4/9/26 and 5/20/26, but the care plan was not updated with new person-centered interventions after those events. On 5/26/26, the resident was found face down on the floor in her room and was later diagnosed with a closed displaced fracture of the right elbow. The investigation identified confusion, wandering, poor safety awareness, improper footwear, and walking without assistance as contributing factors. During observation, the resident stood up unaccompanied, bent over as if to pick something up, and walked toward her room while staff present in the dining room did not provide the touch or verbal cueing described in the care plan.
Failure to Prevent Recurring UTIs
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent recurring UTIs for a resident with a history of UTI, sepsis due to E. coli, hemiplegia/hemiparesis following a stroke, and type 2 diabetes. The resident’s assessments showed moderate cognitive impairment and need for substantial assistance with bathing, dressing, toileting, personal hygiene, and ambulation. The resident also had an active diagnosis of UTI during the assessment period and was receiving antibiotics for infection. The resident and the resident’s representative reported ongoing problems before the sepsis episode. The resident said she had frequent UTIs and had times when she was incontinent and had to wait for staff to change her, leaving her sitting in wet clothes. The representative reported that the resident complained of UTI symptoms for about two weeks without treatment before the condition progressed to sepsis, and that staff were not regularly checking her for incontinence care needs. He also described an episode in which the resident was brought to him with feces running up her back and he had to tell staff she needed to be cleaned and changed. Record review showed the resident had a bowel and bladder care plan with interventions for perineal care, prompted voiding, monitoring for UTI signs and symptoms, and documenting intake and output, but the facility did not identify person-centered interventions to prevent recurring UTIs. Grievances from the resident’s representative stated concerns that the resident’s two-hour toileting/checking program was not being followed and that staff were unaware of the program. Progress notes documented abdominal discomfort, concern for possible UTI, urine testing, continued dysuria, vomiting, sepsis screening, and a urine culture showing E. coli and Aerococcus urinae. The resident was later hospitalized and discharged with severe sepsis due to UTI with ESBL and E. coli. Staff interviews and the ADON’s statements confirmed the facility had an increase in UTIs, including E. coli infections, and that the facility had not audited incontinence care.
Failure to Provide Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with professional standards of practice for two residents by not ensuring oxygen therapy was delivered in accordance with physician orders. One resident had diagnoses including congestive heart failure and chronic respiratory failure with hypoxia, and the record showed a physician order for continuous oxygen at 2 liters per minute by nasal cannula with instructions to verify the resident was wearing oxygen, the tank was full, and the liter flow was correct. The resident’s care plan also identified continuous oxygen therapy, but a grievance form documented that a CNA transferred the resident from the oxygen contractor unit to the portable unit and the resident was without oxygen long enough for the oxygen saturation to drop to 50%. The resident’s representative reported that the portable oxygen tank had been found empty several times and that on one occasion the resident was placed on the stationary concentrator in the room after the portable tank was empty. The representative stated the resident told her she was on 4 liters of oxygen and asked whether that increase was still needed, but she had not been informed of any change in condition or what prompted the increase. The record also showed there was no documentation that the resident was titrated back to the prescribed oxygen rate after the desaturation event. A second resident with chronic respiratory failure with hypoxia and dementia with agitation had a physician order for oxygen at 4 liters continuously. The MDS documented the resident was not receiving oxygen, although observation showed the resident wearing oxygen via nasal cannula. During observation, the portable oxygen tank fill indicator showed only one red light, which staff later confirmed meant the tank was empty. CNA staff stated morning staff were supposed to check the portable tank before transferring the resident from the room concentrator, and one CNA said he would refill it when able because he could not leave the unit immediately. The oxygen care plan was incomplete and did not specify the oxygen setting, delivery method, duration, or whether humidification was needed.
Failure to Address Dementia-Related Aggression and Wandering
Penalty
Summary
The facility failed to ensure residents diagnosed with dementia received individualized treatment and services to address aggressive behavioral symptoms for two residents who displayed aggression toward others. The deficiency involved Resident #6, who had diagnoses including Parkinson’s disease, severe dementia with frontal lobe involvement, cognitive communication deficit, executive function deficit, and a history of aggressive behavior, and Resident #12, who had severe dementia with anxiety, cognitive communication deficit, wandering, and physical behavioral symptoms including hitting, kicking, scratching, grabbing, pushing, and sexually abusive behavior toward others. For Resident #6, the record documented multiple incidents of aggression toward other residents and visitors. In one event, Resident #6 became upset during a struggle over a box of tissues with another resident and scratched that resident, causing a skin tear. In another event, Resident #6 grabbed and shook another resident’s wheelchair after becoming frustrated. In a later incident, Resident #6 approached a resident and his wife in the dining room, kicked their chairs, and told them they were talking too much; staff were observed not intervening immediately, and the resident witness reported the incident to staff to get it de-escalated. The behavior care plan noted a history of verbal aggression, yelling, taunting, non-verbal aggression, pushing, and kicking wheelchairs, with an intervention to redirect the resident to an independent activity if showing behaviors in group settings. For Resident #12, the record documented an incident in which she grabbed a blanket from another resident and hit that resident on the arm three times. During observations on the secure memory care unit, Resident #12 was seen screaming at staff during bathing and later going into other residents’ rooms, while staff did not intervene or provide a person-centered activity to meet her dementia care needs. The behavior care plan identified wandering, attempts to follow staff and visitors off the unit, attempts to open doors, and a history of aggression toward people in her surrounding area, with redirection noted as not generally effective and staff instructed to keep residents separate from others. Despite these documented behaviors and care plan interventions, the observations showed staff did not consistently monitor, intervene, or engage Resident #12 in meaningful activities to address her wandering and aggressive behaviors.
Medication Not Available as Ordered
Penalty
Summary
The facility failed to provide medications as ordered for one resident, specifically failing to have physician-ordered valacyclovir available for administration. The resident had diagnoses including impaired visual function, diabetes, hypertension, and heart failure, and was cognitively intact with minimal assistance needed for activities of daily living. The resident’s vision was impaired and he wore corrective lenses. The resident’s physician orders included valacyclovir 500 mg by mouth three times daily for exposure to keratoconjunctivitis. Record review showed the medication was not administered because the pharmacy would not supply it due to no insurance coverage. An eye care visit documented keratoconjunctivitis in both eyes and keratitis in both eyes, and ordered valacyclovir along with other medications. Nursing notes documented that the resident returned from the eye appointment with these orders and that hospice did not cover the cost of the prescribed eye medications. The record did not show documentation that the eye doctor was informed the resident was not receiving valacyclovir. A fax later sent to the eye doctor stated the orders were open ended and that if hospice did not cover the medications, the doctor needed to discontinue them. There was also no documentation that the facility consulted the medical director or the resident’s primary care physician for an alternative medication treatment when the eye doctor could not be reached.
Infection Control Failures With Vital Signs Equipment and PPE Handling
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection on two of eight units. On one occasion, a CNA entered a COVID-19 positive room with a vital signs machine that did not have disinfectant wipes available on the cart, exited the room without disinfecting the machine, and then took the same machine into another resident’s room. The infection preventionist stated the machine should be wiped down with disinfectant after each use and that carts should contain disinfecting wipes; she also stated staff should not take a vital signs machine used for non-isolation residents into an isolation room. On another occasion, an unidentified CNA took vital signs for four different residents in the secure unit dining room without disinfecting the vital signs machine between each resident’s use. The machine again did not have disinfectant wipes available on the cart. The infection preventionist and assistant director of nursing stated the machine should be disinfected after each use, and the CNA stated staff should be disinfecting the machine after each use and should use the designated equipment in the isolation carts for COVID-19 positive rooms. Housekeeping staff also failed to follow infection control practices in a COVID-19 positive room. An unidentified housekeeper exited the room still wearing full PPE, including a face shield, mask, gloves, and gown, while carrying an open bag of used PPE and trash from the room. The housekeeper then doffed PPE and tied the trash bag closed in the hallway. The infection preventionist stated the housekeeper should not have doffed PPE in the hallway and should not have closed trash bags in the hallway, and the facility policy stated PPE should be removed before exiting the resident’s room except for a respirator, if worn.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances for three residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. The facility's grievance policy, which mandates a review within three calendar days and a written explanation of findings, was not adhered to. The reports for the grievances did not document whether the residents were satisfied with the findings or remedies, nor did they provide information on how to initiate an appeal process to the Grievance Committee. Resident #13, who was cognitively intact and required moderate assistance, reported waiting up to 40 minutes for staff to respond to call lights, resulting in incidents where he defecated in his pants and experienced catheter overflow. Despite filing concern reports on two occasions, there was no documentation of resolution or satisfaction with the outcomes. Similarly, Resident #11, also cognitively intact and requiring maximal assistance, reported waiting up to one hour and 40 minutes for call light responses, leading to instances of urination on herself. Her grievance report also lacked documentation of resolution or satisfaction. Resident #12, who was cognitively intact and required moderate assistance, experienced a fall after waiting one and a half hours for a call light response. His grievance report did not document satisfaction with the findings or provide appeal information. Staff interviews confirmed that call lights were sometimes turned off without addressing residents' needs, and the facility's acceptable call response time was not met. The deficiency highlights the facility's failure to adhere to its grievance policy and ensure timely responses to residents' needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Center At Rock Creek, Llc | 2.1 mi | — | 0 | 0 |
| Good Samaritan Society -- Fort Collins Village | 2.4 mi | ★★★★★ | 12 | 0 |
| Centre Avenue Health And Rehab Llc | 2.9 mi | ★★★★★ | 1 | 0 |
| Creekside Village Rehabilitation And Nursing Llc | 3 mi | ★★★★★ | 34 | 3 |
| Columbine West Health And Rehab Llc | 3 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.