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 July 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.
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.
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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What surveyors actually found near you
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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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Nursing homes near Fort Collins
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 | ★★★★★ | 36 | 3 |
| Columbine West Health And Rehab Llc | 3 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.