Cycle 1
Health 2025-09-11 · Fire 2025-09-11
1 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fort Collins, CO
Lemay Avenue Health And Rehab LLC
5-star overall rating with 5-star inspections with $7,443 in total fines with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4824 S Lemay Ave, Fort Collins, CO
(970) 482-1584
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Columbine Health Systems
Operator or chain grouping
Approved since
1977-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 health / 5 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.27
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.70
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
4.07
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.91
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.40
CMS adjusted RN staffing hours
Adjusted total hours
4.85
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,090
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9942
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.78
Baseline 16.82% · Performance 20.14% · Measure score 2.78 · Achievement 2.78 · Improvement 0
Healthcare-associated infections
3.57
Baseline 4.74% · Performance 6.77% · Measure score 3.57 · Achievement 3.57 · Improvement 0
Total nurse turnover
4.39
Performance 45.73% · Measure score 4.39 · Achievement 4.39 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.80
Baseline 3.79 hours · Performance 4.73 hours · Measure score 5.80 · Achievement 5.80 · Improvement 4.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.71% |
10.72%
2 pts better
|
No Different than the National Rate · Eligible stays 325 · Observed rate 6.15% · Lower 95% interval 6.13% |
| Discharge to community | 67.01% |
50.57%
16.4 pts better
|
Better than the National Rate · Eligible stays 297 · Observed rate 67% · Lower 95% interval 62.9% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.32% |
95.27%
4 pts better
|
Numerator 147 · Denominator 148 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 148 |
| Discharge self-care score | 50.35% |
53.69%
3.3 pts worse
|
Numerator 72 · Denominator 143 |
| Discharge mobility score | 62.24% |
50.94%
11.3 pts better
|
Numerator 89 · Denominator 143 |
| Pressure ulcers or injuries, new or worsened | 2.03% |
2.29%
0.3 pts better
|
Numerator 3 · Denominator 148 · Adjusted rate 2.74% |
| Healthcare-associated infections requiring hospitalization | 6.77% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 169 · Observed rate 5.33% · Lower 95% interval 4.25% |
| Staff COVID-19 vaccination coverage | 10.28% |
8.2%
2.1 pts better
|
Numerator 26 · Denominator 253 |
| Staff flu vaccination coverage | 96.79% |
42%
54.8 pts better
|
Numerator 483 · Denominator 499 |
| Discharge function score | 60.14% |
56.45%
3.7 pts better
|
Numerator 86 · Denominator 143 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 89 · Denominator 89 |
| Resident COVID-19 vaccinations up to date | 53.25% |
25.2%
28.1 pts better
|
Numerator 41 · Denominator 77 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.3
0.4 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
93.5%
6.2 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.4%
2.4 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 7.3% · Q3 6.1% · Q4 2.9% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
7.4%
5.6 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.1% · Q3 3.2% · Q4 2.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
5.0%
2.3 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.4% · Q3 2.4% · Q4 2.2% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.9% |
11.2%
4.7 pts worse
|
19.6%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 14.6% · Q3 15.1% · Q4 16.1% · 4Q avg 15.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.7% |
20.6%
1.9 pts better
|
16.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 18.1% · Q3 18.9% · Q4 17.7% · 4Q avg 18.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.6% |
15.2%
14.4 pts worse
|
16.3%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 37.3% · Q3 30.3% · Q4 25.5% · 4Q avg 29.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.4% |
14.6%
5.8 pts worse
|
14.9%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 18.4% · Q3 18.8% · Q4 16.3% · 4Q avg 20.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.8%
0.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.5%
0.7 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
22.4%
1.5 pts better
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.0% · Q2 18.6% · Q3 23.3% · Q4 17.8% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
3.7%
0.5 pts worse
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.9% · Q3 5.0% · Q4 4.5% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
76.4%
18.8 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 97.1% · Q3 93.7% · Q4 91.3% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
12.8%
1 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 12.6% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.9% · Q3 0.9% · Q4 2.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
75.6%
16.4 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.7% |
20.3%
0.6 pts better
|
23.9%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 16.5% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-08-19 · Fire 2022-08-19
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-12-19
E · Potential for more than minimal harm
2025-09-11
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-12-19
E · Potential for more than minimal harm
2025-09-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-12-22
E · Potential for more than minimal harm
2025-09-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-12-22
E · Potential for more than minimal harm
2025-09-11
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-12-19
F · Potential for more than minimal harm
2023-11-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-14
D · Potential for more than minimal harm
2023-11-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-14
D · Potential for more than minimal harm
2023-11-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-02-19
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2025-03-10
F · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-06
G · Actual harm
2023-07-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-27
D · Potential for more than minimal harm
2022-08-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-09-13
D · Potential for more than minimal harm
2022-08-19
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-09-13
D · Potential for more than minimal harm
2022-08-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-17
Penalties and ownership
What sits behind the stars
$7,443
2023-07-26
Fine
Fine · fine $7,443
Fine
Ownership
Wilson, John
5% Or Greater Direct Ownership Interest · Individual
Columbine Management Services Inc
Operational/Managerial Control · Organization
Fancher, Barry
Corporate Officer · Individual
Fancher, Barry
W-2 Managing Employee · Individual
Fasciano-Sager, Lauren
Corporate Officer · Individual
Fasciano-Sager, Lauren
W-2 Managing Employee · Individual
Wilson, John
Corporate Director · Individual
Wilson, John
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Good Samaritan Society -- Fort Collins Village
Fort Collins, CO
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Centre Ave Health And Rehabilitation LLC
Fort Collins, CO
5-star overall rating with 5-star inspections with $8,044 in total fines with 7 fire-safety deficiencies in the latest cycle
#3
Creekside Village Rehabilitation And Nursing LLC
Fort Collins, CO
1-star overall rating with 1-star inspections with abuse icon flag with $28,042 in total fines with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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