LEMAY AVENUE HEALTH AND REHABILITATION FACILITY
The information listed below provides an in-depth look into the type and quality of care offered at Lemay Avenue Health and Rehabilitation Facility. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.
Address
LEMAY AVENUE HEALTH AND REHABILITATION FACILITY
4824 SOUTH LEMAY AVENUE
FORT COLLINS, CO 80525
(970) 482-1584
4824 SOUTH LEMAY AVENUE
FORT COLLINS, CO 80525
(970) 482-1584
Nursing Home Ratings
| Health Inspections | |
| Quality Measures | |
| Nursing Staff | |
| R.N. Staff Only | |
| Overall Rating | |
Percent of Beds Occupied
90%Number of Residents and Certified Beds
- Residents: 117
- Certified Beds: 130
This Facility Accepts
- Medicare
- Medicaid
Operational Details
- Operated By For Profit - Corporation
- Offers Only Resident Counseling
- This Facility is Part of a Chain or Franchise
Resident Services
The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Very High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by Lemay Avenue Health and Rehabilitation Facility. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.
| Resident Services | Resident Conditions | Percent of Service Days |
Ultra-High Rehabilitation Plus Extensive Services
Rehabilitation 720 Minutes Per Week Minimum
- At least one rehabilitation discipline five days/week
- A second rehabilitation discipline three days/week
- Tracheostomy care
- Ventilator or respirator
- Isolation for active infectious disease while a resident
- Activities of Daily Living (ADL) score of 2 or more
| ADL Index Range: 11-16 | 1.0% |
| ADL Index Range: 2-10 | 0.7% |
| Total Percent: | 1.7% |
Very High Rehabilitation Plus Extensive Services
Rehabilitation 500 Minutes Per Week Minimum
- At least one rehabilitation discipline five days/week
- Tracheostomy care
- Ventilator or respirator
- Isolation for active infectious disease while a resident
- Activities of Daily Living (ADL) score of 2 or more
| ADL Index Range: 11-16 | 1.2% |
| ADL Index Range: 2-10 | 3.3% |
| Total Percent: | 4.5% |
High Rehabilitation Plus Extensive Services
Rehabilitation 325 Minutes Per Week Minimum
- At least one rehabilitation discipline five days/week
- Tracheostomy care
- Ventilator or respirator
- Isolation for active infectious disease while a resident
- Activities of Daily Living (ADL) score of 2 or more
| ADL Index Range: 2-10 | 2.2% |
| Total Percent: | 2.2% |
Ultra-High Rehabilitation
Rehabilitation 720 Minutes Per Week Minimum
- At least one rehabilitation discipline five days/week
- A second rehabilitation discipline three days/week
| ADL Index Range: 11-16 | 8.0% |
| ADL Index Range: 6-10 | 6.0% |
| ADL Index Range: 0-5 | 7.1% |
| Total Percent: | 21.0% |
Very High Rehabilitation
Rehabilitation 500 Minutes Per Week Minimum
- At least one rehabilitation discipline five days/week
| ADL Index Range: 11-16 | 19.2% |
| ADL Index Range: 6-10 | 23.9% |
| ADL Index Range: 0-5 | 6.0% |
| Total Percent: | 49.1% |
High Rehabilitation
Rehabilitation 325 Minutes Per Week Minimum
- At least one rehabilitation discipline five days/week
| ADL Index Range: 11-16 | 1.6% |
| ADL Index Range: 6-10 | 10.3% |
| ADL Index Range: 0-5 | 6.8% |
| Total Percent: | 18.8% |
Medium Rehabilitation
Rehabilitation 150 Minutes Per Week Minimum
- Five days any combination of three rehabilitation disciplines
| ADL Index Range: 11-16 | 0.9% |
| ADL Index Range: 6-10 | 0.5% |
| ADL Index Range: 0-5 | 1.1% |
| Total Percent: | 2.5% |
Special Care High
- Comatose
- Septicemia
- Diabetes with daily injections and a change of order two or more days
- Quadriplegia with ADL score greater or equal to 5
- Chronic Obstructive Pulmonary Disease (COPD) and shortness of breath when lying flat
- Fever with pneumonia, or vomiting, or weight loss, or feeding tube
- Parenteral/IV feedings
- Respiratory therapy for 7 days
- Activities of Daily Living (ADL) score of 2 or more
| ADL Index Range: 15-16 - Signs of depression | 0.06% |
| Total Percent: | 0.06% |
Clinically Complex
- Pneumonia, hemiplegia with ADL score >=5
- Surgical wounds or open lesions with treatment
- Burns
- Chemotherapy while a resident
- Oxygen therapy while a resident
- IV medications or transfusions while a resident
- Extensive Services, Special Care High or Special Care Low qualifier and ADL score of 0 or 1
| ADL Index Range: 11-14 - No Signs of depression | 0.1% |
| Total Percent: | 0.1% |
Rating Details For Lemay Avenue Health and Rehabilitation Facility
Nursing Staff - 
The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.
| Nursing Hours Per Resident Per Day | Reported | Expected |
| Registered Nurse (RN) Hours | 1 Hour and 10 Minutes | 1 Hour and 16 Minutes |
| Licensed Practical/Vocational Nurse (LPN/LVN) Hours | 39 Minutes | 45 Minutes |
| Certified Nursing Assistant (CNA) Hours | 2 Hours and 56 Minutes | 2 Hours and 36 Minutes |
| Total Licensed Nurse Hours | 1 Hour and 48 Minutes | 2 Hours and 1 Minutes |
| Total Nurse Hours | 4 Hours and 44 Minutes | 4 Hours and 37 Minutes |
Quality of Care -
Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Colorado are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.
| This Facility | Colorado Average |
Long-Term Stay Preventive Actions
| Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 88% |
| Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 87% |
Long-Term Stay Deficiencies
| Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder | 66% | 48% |
| Percent of Long-Stay Residents Who Are More Depressed or Anxious | 20% | 16% |
| Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores | 3% | 3% |
| Percent of High-Risk Long-Stay Residents Who Have Pressure Sores | 7% | 9% |
| Percent of Long-Stay Residents Who Have Moderate to Severe Pain | 1% | 4% |
| Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder | 8% | 7% |
| Percent of Long-Stay Residents Who Were Physically Restrained | 1% | 4% |
| Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair | 3% | 3% |
| Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse | 8% | 11% |
| Percent of Long-Stay Residents Who Lose Too Much Weight | 14% | 8% |
| Percent of Long-Stay Residents Who Had a Urinary Tract Infection | 21% | 9% |
| Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased | 11% | 15% |
Short-Term Stay Preventive Actions
| Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 85% | 79% |
| Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season | 73% | 81% |
Short-Term Stay Deficiencies
| Percent of Short-Stay Residents Who Had Moderate to Severe Pain | 10% | 23% |
| Percent of Short-Stay Residents Who Have Pressure Sores | 3% | 9% |
| Percent of Short-Stay Residents Who Have Delirium | 1% | 3% |
Health Inspection Details - 
All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 10/01/2010.
Degree of Harm
- Potential for Minimal Harm
- Minimal Harm or Potential for Harm
- Resident Harmed
- Immediate Jeopardy to Resident Health
Residents Affected
- Isolated
- Some Residents
- Many Residents
| Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Environmental
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
|  |  |
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Have a Program to Keep Infection from Spreading.
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Mistreatment
1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
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1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
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Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment.
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Nutrition and Dietary
Prepare Food That is Nutritional, Appetizing, Tasty, Attractive, Well-Cooked, and at the Right Temperature.
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Store, Cook, and Give out Food in a Safe and Clean Way.
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Pharmacy Service
Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%.
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1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
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Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
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1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
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Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
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At Least Once a Month, Have a Licensed Pharmacist Check the Drugs That Each Resident Takes.
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Quality Care
Give Professional Services That Meet a Professional Standard of Quality.
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Provide Social Services for Related Medical Problems to Help Each Resident Achieve the Highest Possible Quality of Life.
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Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
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Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
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Properly Care for Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, and Prostheses.
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Give Professional Services That Meet a Professional Standard of Quality.
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Resident Assessment
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
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Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
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Resident Rights
Let the Resident Refuse Treatment or Refuse to Take Part in an Experiment.
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Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
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Give the Resident's Legal Representative the Same Rights As the Resident.
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Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items and Services Medicaid Covers and Which the Resident Must Pay For; or 2) How to Apply for Medicaid, Along with the Names and Addresses of State Groups That Can Help.
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Allow Residents to Easily See the Results of the Nursing Home's Most Recent Survey.
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Give Enough Notice to the Resident Before Changing the Resident's Room or Roommate.
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Enforcement
Below is a list of any civil penalities or denials of payment for new admissions (DPNA) that this facility received in the previous three years. Note: Monetary figures are not available for DPNAs.
| Action Taken | Date | Amount |
| Civil Money Penalty (CMP) | 05/07/2010 | $975 |
Deficiencies from Complaints and Incidents
The table below lists incident reports by the nursing staff or administration for Lemay Avenue Health and Rehabilitation Facility, as well as complaints by residents or their family in the previous three years.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
| Formal Complaints | Degree of Harm | Residents Affected |
Administration
Be Administered in a Way That Leads to the Highest Possible Level of Well Being for Each Resident.
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Choose a Doctor to Be the Medical Director.
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Set Up or Keep a Group of People to Review and Ensure Quality.
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Mistreatment
Protect Residents from Mistreatment, Neglect, And/Or Theft of Personal Property.
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1) Hire Only People Who Have No Legal History of Abusing, Neglecting or Mistreating Residents; or 2) Report and Investigate Any Acts or Reports of Abuse, Neglect or Mistreatment of Residents.
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Quality Care
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
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Give Each Resident Enough Fluids to Keep Them Healthy and Prevent Dehydration.
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Resident Assessment
Make Sure That Doctors Visit Residents Regularly, As Required.
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Resident Rights
Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged.
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Fire Safety
Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Lemay Avenue Health and Rehabilitation Facility had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 10/29/2010.
Degree of Harm
- - Potential for Minimal Harm
- - Minimal Harm or Potential for Harm
- - Resident Harmed
- - Immediate Jeopardy to Resident Health
Residents Affected
- - Isolated
- - Some Residents
- - Many Residents
| Deficiencies Found By Inspectors | Degree of Harm | Residents Affected |
Building Construction
A Two-Hour-Resistant Firewall in Common Walls.
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Building Service Equipment
Properly Constructed Linen or Trash Chutes.
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Properly Protected Cooking Facilities.
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Corridor Walls and Doors
Corridor and Hallway Doors That Block Smoke.
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Corridor and Hallway Doors That Block Smoke.
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Electrical
The Appropriate Emergency Electrical Equipment.
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Weekly Inspections and Monthly Testing of Generators.
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Properly Installed Electrical Wiring and Equipment.
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Emergency Plans and Fire Drills
Did Not Have a Written Emergency Evacuation Plan.
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Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
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Exits and Egress
Exits That Are Accessible at All Times.
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Fire Alarm Systems
A Fire Alarm System That Can Be Heard Throughout the Facility.
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Properly Maintained Smoke Detectors.
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Furnishings and Decorations
Exits That Are Free from Obstructions and Can Be Used at All Times.
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Restrictions on the Use of Highly Flammable Materials.
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Restrictions on the Use of Flammable Curtains.
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Hazardous Area
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
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Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
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Smoke Compartmentation and Control
Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
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Smoking Regulations
Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed.
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Vertical Openings
Protected Exits That Allow the Resident to Escape the Building.
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Source: Medicare Nursing Home Compare; Colorado Department of Public Health and Environment - Retrieved 2011
