Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Storybrook Care & Rehabilitation during CMS and state inspections, most recent first.
A nurse performed a PICC line dressing change for a resident without following professional standards, including turning away from the sterile field, leaving the line exposed, not cleaning the site for the recommended duration, failing to measure catheter length, and not wearing a protective gown. The nurse had not received facility-specific training or demonstrated competency in PICC line care, and neither of the two nurses on staff had been trained in PICC line management.
A facility failed to ensure proper infection prevention and control by not implementing enhanced barrier precautions (EBP) during high-contact care activities for a resident with a PICC line. Staff did not wear gowns as required during a dressing change and incontinence care, despite clear signage and CDC guidance. Interviews revealed gaps in staff understanding and adherence to EBP protocols.
Two residents who experienced falls were not assessed by an RN as required, and one resident on anticoagulant therapy did not receive consistent neurological monitoring after a head injury. Instead, LPNs performed the initial assessments, and in one case, the resident was not sent for emergency evaluation despite ongoing symptoms. Documentation and staff interviews confirmed that RN assessment was not completed or documented, and scheduled neurological checks were missed.
A resident with severe cognitive impairment and behavioral issues struck another cognitively impaired resident in the arm while both were in the dining area. Staff separated the residents and reported completing skin assessments, but documentation for the victim's assessment was missing. The aggressor's behavioral care plan was created only after the incident, and the victim's medical record did not include notes about the altercation. Staff interviews confirmed the event and the lack of documentation, leading to a deficiency for failure to prevent and document resident-to-resident physical abuse.
The facility did not ensure an adequate supply of clean linens, resulting in some residents missing showers and bed baths, and failed to maintain clean floors in resident rooms, hallways, and the main dining room. Staff and resident interviews, along with direct observations, confirmed ongoing linen shortages, confusion over responsibilities, and insufficient cleaning practices due to limited housekeeping staff.
A resident with multiple sclerosis and muscle weakness developed an unstageable pressure injury due to the facility's failure to consistently implement physician-ordered off-loading boots. Despite being at moderate risk for pressure injuries, the resident's care plan lacked specific interventions for foot protection. Observations showed the resident often without the boots, contradicting staff claims of compliance. The facility's documentation did not reflect consistent preventive measures, leading to the development of a pressure injury.
The facility failed to honor residents' rights to hold private council meetings without staff presence and did not adequately address grievances regarding food quality and dietary options. Residents reported dissatisfaction with the facility's responses, and staff interviews revealed a lack of proper coordination and follow-up on resident council meetings.
The facility failed to provide ongoing communication about resident rights and responsibilities. Despite having a policy requiring oral and written communication, residents reported not receiving ongoing discussions about their rights. Interviews and record reviews confirmed that resident rights were not reviewed during council meetings, leading to the deficiency.
A facility failed to address a resident's grievances about stolen items and did not ensure residents knew how to file grievances. A resident reported stolen items and filed grievances without resolution. A group of residents was unaware of grievance procedures, and observations showed inadequate signage and accessibility of grievance information. Staff interviews confirmed these deficiencies.
The facility failed to provide timely dental services for three residents, resulting in unresolved issues with missing or ill-fitting dentures. Despite grievances and reports, there was no documentation of dental consultations or interventions. Staff interviews revealed a lack of awareness and follow-up, with the social services department failing to coordinate necessary dental services as per facility policy.
The facility failed to provide palatable and properly prepared meals, as reported by residents and observed during a lunch meal. Residents described the food as overcooked, watery, and lacking variety. Observations confirmed issues with food presentation and taste, such as dry chicken and bland rice pilaf. Interviews with the dietary manager and NHA acknowledged these deficiencies.
The facility failed to accommodate dietary preferences for three residents, including a vegetarian resident who had to purchase her own food due to limited options, a diabetic resident who desired more dessert variety, and another diabetic resident who struggled with high blood glucose levels due to carbohydrate-heavy meals. Staff acknowledged the oversight and limited options available.
The facility failed to maintain proper food handling and hygiene practices, including improper labeling and storage of food, unclean kitchen equipment, and inadequate hand hygiene by staff. Food items were not labeled or dated correctly, and some were stored on the floor. A commercial mixer was found with old food residue, and staff did not change gloves or wash hands between tasks, as observed by surveyors.
A facility failed to incorporate PASRR Level II recommendations into a resident's care plan, neglecting to provide specialized services such as case management and therapy. The resident, with multiple diagnoses including bipolar disorder and PTSD, did not receive the necessary services as documented in the PASRR report. The facility's policy required these recommendations to be included in the care plan, but this was not done until the survey period.
The facility failed to maintain a sanitary and functional laundry area. Clean hoyer slings were found hanging in the dirty laundry room, with some touching the ground and a mop bucket. The ceiling above the washing machines was damaged, and clean blankets were improperly stored. The door between clean and dirty areas could not be closed. Staff interviews revealed a recent leak and a need for repairs.
Failure to Follow Professional Standards During PICC Line Dressing Change
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality during a peripherally inserted central catheter (PICC) line dressing change for one resident. During the observed procedure, the registered nurse (RN) turned his back on the sterile field multiple times, left the resident's room to obtain additional supplies after removing the PICC line dressing—leaving the line exposed—and did not follow the recommended cleaning technique or duration for the insertion site. The RN also failed to measure the length of the catheter to monitor for migration and did not wear a protective gown as required. These actions were not in accordance with established professional guidelines for PICC line care. Record review revealed that the RN had not completed training or demonstrated competency in PICC line dressing changes at the facility. Interviews with the RN, the director of nursing (DON), and the infection preventionist (IP) confirmed that neither of the two nurses currently working at the facility had received training for PICC line management. The RN admitted to lacking formal training at the facility and expressed a desire for education, attributing his errors during the procedure to nervousness and unfamiliarity with the facility's protocols.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program, specifically regarding the implementation of enhanced barrier precautions (EBP) for residents with indwelling medical devices. According to CDC guidance, EBP requires the use of gowns and gloves during high-contact resident care activities for residents with wounds or indwelling devices, regardless of known colonization with multidrug-resistant organisms (MDROs). The facility's policy addressed standard transmission-based precautions but did not mention or address EBP, despite signage indicating EBP requirements on a resident's door. During observations, a registered nurse (RN) was seen performing a peripherally inserted central catheter (PICC) line dressing change for a resident who was admitted for antibiotic treatment and IV management. The RN wore gloves and a mask but failed to don a protective gown as required by EBP. Additionally, a certified nurse aide (CNA) assisted the same resident with transferring and incontinence care but did not wear a gown, only gloves, despite the resident being on EBP due to the presence of an IV line. Interviews with the involved staff revealed a lack of understanding and adherence to EBP protocols. The CNA believed that only gloves were necessary for personal care and did not recognize the need for a gown when assisting with transfers or incontinence care for a resident with an indwelling device. The RN acknowledged forgetting to wear a gown during the dressing change. The infection preventionist confirmed that both staff members should have used gowns and gloves for these high-contact activities, as required by EBP.
Failure to Ensure RN Assessment and Adequate Monitoring After Resident Falls
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans. Specifically, two residents who experienced falls were not assessed by a registered nurse (RN) following their incidents, and in one case, a resident on anticoagulant medication did not receive consistent and increased monitoring after sustaining a head injury. The records showed that after a fall, a licensed practical nurse (LPN) performed the initial assessment, but there was no documentation of RN involvement or consultation, despite facility policy and professional standards requiring RN assessment, especially in cases involving head injuries or anticoagulant use. One resident, with a history of atrial fibrillation, muscle weakness, and difficulty walking, was taking Eliquis, an anticoagulant. After an unwitnessed fall where she hit her head, the resident was evaluated by an LPN, who found no injuries. However, the resident began complaining of headache and neck pain later that morning. Despite these symptoms and her anticoagulant use, the facility did not send her to the emergency department for further evaluation and did not increase monitoring beyond the standard neurological assessment protocol. Neurological assessments were not completed consistently as scheduled, and three days after the fall, the resident was transported to the hospital, where a significant subdural hemorrhage was diagnosed. Another resident, with severe cognitive impairment and a history of falls, was found on the floor with a head laceration and a large skin tear after a fall. The LPN on duty performed the assessment and assisted the resident from the floor before EMS was called. There was no documentation that an RN assessed the resident prior to her being moved. Staff interviews confirmed that facility policy required RN assessment after falls, particularly for residents on blood thinners or with head injuries, but at the time of both incidents, no RN was present in the building, and no RN assessment was documented.
Failure to Prevent and Document Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. On the date of the incident, one resident with severe cognitive impairment and a history of behavioral issues, including agitation and aggression, struck another resident, also with severe cognitive impairment, in the arm while both were in the dining room. The residents were immediately separated, and skin assessments were reportedly completed, though no injuries were observed. However, the facility was unable to provide documentation of the skin assessments for the resident who was struck. The investigation into the incident revealed that both residents resided in the memory care unit and were dependent on staff for most activities of daily living. The resident who struck the other had a care plan for behavioral problems, but this plan was only created after the incident, during the survey. The other resident, who was the victim, had a care plan that included interventions to prevent behavioral escalation and to avoid positioning near others who might disturb her, but there was no documentation in her medical record regarding the physical altercation. Staff interviews confirmed the event, with the registered nurse on duty recalling that the residents were in close proximity and that the aggressor was agitated at the time. The nurse assessed the victim, but neither resident expressed fear of the other. The nursing home administrator and director of nursing agreed with the documentation in the records and investigation reports but could not provide the required skin assessment documentation for the victim. The facility's failure to prevent the physical abuse and to document the required assessments contributed to the deficiency.
Failure to Provide Adequate Linens and Maintain Cleanliness
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents by not ensuring an adequate supply of clean linens and by not maintaining clean floors in resident rooms, hallways, and the main dining room. Multiple residents reported not receiving showers or bed baths due to a lack of clean linens, and this issue was corroborated by staff interviews and direct observation of insufficient linen supplies in storage areas. Staff described ongoing problems with linen shortages, confusion over responsibilities for ordering and stocking linens, and instances where stained linens were discarded without attempts to clean them. The director of nursing was unaware that the linen shortage was affecting resident care, and the nursing home administrator did not know the current par levels for linens. Observations revealed that the linen storage closet contained very few clean linens, and the laundry room had no clean linens being folded or stored at the time of inspection. Staff interviews indicated that the shortage of linens had been an ongoing issue, particularly after a change in facility ownership, and that staff often had to improvise by using blankets in place of towels. There was also a disconnect between laundry and floor staff, with the laundry room being locked on weekends and unclear communication about linen availability and responsibilities. In addition to linen shortages, the facility failed to maintain clean floors in resident rooms, hallways, and the main dining room. Observations documented visible debris, dried spills, dust, and wheelchair tracks in these areas. Housekeeping staff reported limited staffing, with only one housekeeper on some days, and cleaning schedules that did not ensure daily cleaning of all areas. The maintenance supervisor and housekeeper both expressed uncertainty about the frequency of deep cleaning and whether the dining room was cleaned after each meal, raising concerns about the adequacy of cleaning practices throughout the facility.
Failure to Implement Pressure Injury Prevention Measures
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries for a resident diagnosed with multiple sclerosis and generalized muscle weakness. Upon admission, the resident had intact skin on the feet and heels and was assessed as being at moderate risk for pressure injuries due to impaired mobility and bowel incontinence. Although a skin care plan was initiated, it lacked specific interventions to prevent pressure injuries on the resident's feet. A physician's order for off-loading boots was obtained, but staff did not consistently implement this intervention. Observations during the survey revealed that the resident's off-loading boots were often not worn as ordered. The resident was seen in bed and in a wheelchair without the boots, despite the physician's order for them to be worn at all times. Consequently, the resident developed an unstageable pressure injury on the plantar surface of the left foot. Staff interviews confirmed that the resident did not refuse to wear the boots, contradicting claims that the resident refused them at night. The facility's documentation and staff interviews indicated a lack of consistent implementation of pressure injury prevention measures. The resident's care plan did not include specific interventions for offloading the feet, and there was no documentation of turning and repositioning or timely initiation of a protein supplement. The wound care provider did not assess the wound until several days after it developed, and the treatment administration record inaccurately documented that the boots were worn every shift.
Failure to Honor Resident Council Rights and Address Grievances
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in resident/family groups without staff presence, as required by their policy. During a group interview, residents reported that their council meetings were held in a large dining room with the door open, allowing staff, visitors, and other residents to enter and exit freely. This setup did not provide the residents with the opportunity to meet privately without staff present, which is a violation of their rights. Additionally, the facility did not provide a private space for the resident council meetings, further compromising the residents' ability to discuss their concerns freely. The residents expressed dissatisfaction with the facility's response to their grievances, particularly regarding food quality and dietary options. Residents reported a lack of vegetarian protein choices, insufficient diabetic dessert options, and issues with the food being overcooked and watery. Despite these concerns being raised in resident council meetings, there was no documentation of the facility providing a response, action, or rationale to address these issues. The dietary manager's responses were noted, but there was no evidence that the residents approved these responses or that their concerns were resolved. Interviews with staff, including the activities director and the nursing home administrator, revealed a lack of proper coordination and follow-up on resident council meetings. The activities director admitted to not offering residents the opportunity to meet without staff present and not ensuring that the residents approved the responses to their concerns. The nursing home administrator was unaware of these issues and acknowledged that the resident council concern forms were incomplete, lacking documentation of resident approval. This lack of proper procedure and documentation contributed to the facility's failure to adequately address and resolve the residents' grievances.
Failure to Communicate Resident Rights
Penalty
Summary
The facility failed to provide ongoing communication to residents about their rights and responsibilities, as required by their policy. The Resident Rights policy, revised in August 2024, mandates that information about resident rights and responsibilities be given both orally and in writing. However, during a group interview with five alert and oriented residents, four of them reported that the facility did not provide ongoing discussions to review and explain their rights and responsibilities. These residents were unaware that their rights were posted on a wall in the facility, indicating a lack of effective communication from the facility. Further investigation into the facility's practices revealed that the resident council monthly minutes from July 2024 through September 2024 did not document any discussions or reviews of resident rights. Interviews with the Activities Director (AD) and the Nursing Home Administrator (NHA) confirmed that resident rights were not reviewed during resident council meetings. The NHA acknowledged that while rights were initially reviewed at admission and posted on a wall, there was no ongoing discussion or documentation of such reviews, contributing to the deficiency.
Failure to Address Grievances and Inform Residents
Penalty
Summary
The facility failed to promptly address grievances related to lost or stolen items for a resident and did not ensure that residents had adequate information on how to file grievances. Resident #28, who was cognitively intact, reported multiple instances of personal items being stolen, including a sweatshirt, a towel, and cash totaling $100. Despite filing several grievances, the resident did not receive a resolution. The facility's records did not show any attempts to resolve these grievances, and staff interviews revealed a lack of consistent procedures for addressing such complaints. Additionally, a group interview with five alert and oriented residents revealed that several of them were unaware of how to file a grievance. Observations within the facility showed that the grievance policy was posted in a location that was not easily accessible or readable for all residents, particularly those in wheelchairs. The grievance forms were placed in a wall file without any clear signage indicating their purpose, contributing to the residents' lack of awareness. Interviews with staff, including the Nursing Home Administrator (NHA), confirmed that there was no sign next to the grievance forms, and the font size of the posted grievance policy was too small for some residents to read. The NHA acknowledged these issues and noted that the Social Services Director, who was responsible for managing grievances, was unavailable during the survey due to illness.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to assist residents in obtaining necessary dental services, specifically in replacing missing or ill-fitting dentures for three residents. Resident #10, who was cognitively intact, reported her lower dentures missing since February 2024 and filed a grievance form. Despite this, there was no documentation of a dental appointment or intervention to address her missing dentures. Similarly, Resident #11, also cognitively intact, lost her lower dentures and had not seen a dentist for replacement, affecting her food choices. The facility's records did not show any dental consultation or follow-up for her missing dentures. Resident #17 experienced issues with ill-fitting lower dentures that would pop out during meals. Despite being informed that a dentist would address the fit, she had not seen a dentist since October 2023. The facility's records lacked documentation of any follow-up or interventions to address her dental concerns. Interviews with staff revealed a lack of awareness and follow-up on missing dentures, with the social services department being responsible for coordinating dental services, which was not effectively executed. The facility's policy required referral for dental services within three days for lost or damaged dentures, but this was not adhered to. The Regional Clinical Resource (RCR) acknowledged the overdue resolution of grievances and the absence of documented interventions for the affected residents. The RCR also noted the lack of timely follow-up and documentation of dental appointments, assessments, and interventions in the residents' records, highlighting a systemic failure in addressing dental care needs.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to consistently serve food that was palatable, attractive, and at the appropriate temperature, as evidenced by multiple resident interviews, observations, and record reviews. Residents reported that the food was often overcooked, watery, dry, or bland, and expressed a desire for more fresh fruit and diabetic dessert options. During a group interview, several residents described the food as unpalatable, with issues such as overcooked and watery dishes. Individual interviews echoed these concerns, with one resident noting the need to order take-out due to the poor quality of meals. Resident council meeting notes from July and August 2024 highlighted ongoing complaints about the food, including excessive seasoning, watery soup, and a lack of variety. Observations during a lunch meal revealed that the food did not meet the facility's standards for palatability and presentation. The bread rolls were smashed and stuck together, the chicken was dry and lacked flavor, and the rice pilaf was bland. Additionally, the wrong type of peas was served, and the spiced peaches tasted like canned fruit with cinnamon. Interviews with the dietary manager and nursing home administrator confirmed these issues, with the dietary manager acknowledging that the food did not meet the expected standards for taste and presentation. The facility's failure to provide palatable and properly prepared meals was evident through these findings.
Deficiency in Accommodating Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated resident preferences for three residents, leading to a deficiency in dietary services. Resident #31, a 69-year-old with severe cognitive impairments and on a therapeutic diet, reported insufficient vegetarian meal options, resulting in her purchasing her own food. Observations confirmed that the resident was not provided with a vegetarian protein option, despite her dietary requirements being documented. The dietary manager acknowledged the oversight and attributed it to changes in food ordering processes. Resident #17, who is cognitively intact and has diabetes and dysphagia, expressed dissatisfaction with the limited diabetic dessert options, specifically the lack of variety beyond jello. The resident also desired more fresh fruit options, as the facility only provided canned fruit. This indicates a failure to meet the resident's dietary preferences and needs, as documented in the resident's interview. Resident #6, with moderately impaired cognition and diabetes, reported that the facility's menu was not diabetic-friendly, with a heavy emphasis on carbohydrates. The resident struggled with high blood glucose levels, which she attributed to the hidden sugars in the food, such as canned fruit. The resident council meeting notes corroborated her request for more diabetic dessert options, highlighting the facility's limited offerings of sugar-free jello and pudding. Staff interviews confirmed the lack of variety in diabetic snacks and desserts.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and hygiene standards in the main kitchen, as observed during a survey. The deficiencies included improper labeling and dating of food items, with some containers lacking labels entirely or having unclear dates. For instance, a container of Raisin Bran was found without any label or date, and the labeling on a Rice Krispies container did not specify whether the date was for opening or use by. The dietary manager acknowledged these lapses, stating that food removed from original packaging should be labeled with the name, opening date, and discard date. Additionally, the facility did not adhere to the requirement of storing food at least six inches above the floor. During the kitchen tour, several food items, including a large box of chips, bottles of vinegar, and boxes of soda, were found stored directly on the floor in the dry storage area. The dietary manager admitted that staff were aware of the requirement to keep food off the ground but cited the small kitchen size as a challenge for proper storage. The facility also failed to ensure that kitchen equipment was clean, as evidenced by a commercial mixer covered with dry, dark brown food residue from a previous use over a week prior. Despite the dietary manager's acknowledgment of the issue, the mixer remained uncleaned during subsequent observations. Furthermore, staff did not perform appropriate hand hygiene and glove usage in the dining room. Dietary aides were observed handling meal trays, refilling drinks, and assisting residents without changing gloves or performing hand hygiene between tasks, which was confirmed by the regional clinical resource covering for the infection preventionist.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) Level II determination into the assessment, care planning, and transition of care for a resident. The resident, a 72-year-old with multiple diagnoses including bipolar disorder, PTSD, and dementia, was identified as requiring specialized services such as case management, psychiatric case consultation, and individual therapy. However, the facility did not document these recommendations in the resident's comprehensive care plan or ensure that the services were provided. The facility's policy required that PASRR Level II recommendations be incorporated into the resident's care plan, but this was not done until the survey period. Interviews with staff revealed that the recommendations were not included in the social services assessment or the care plan, and there was no documentation of the resident receiving the recommended services. An appointment was scheduled but not attended, and a new appointment was set for a later date. The failure to implement the PASRR Level II recommendations was acknowledged by the facility's staff during the survey.
Deficiency in Laundry Room Maintenance
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the laundry area. Observations revealed multiple clean resident hoyer slings hanging in the dirty laundry room with their straps touching the ground and one sling touching a mop bucket. The ceiling above the washing machines was damaged with peeling paint above where clean laundry would be removed. Clean, folded blankets were found partially bagged in black trash bags on the floor next to the slings. Additionally, the door between the clean and dirty laundry rooms could not be closed due to a shift in the door frame. Interviews with staff indicated that there had been a recent leak in the laundry room, and repairs to the ceiling were needed. The director of housekeeping, who was new to the role, was unaware that the placement of clean slings in the laundry room could cause contamination. The director also mentioned that the facility needed to order a fire door to replace the existing one between the clean and dirty areas.
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Illustrative
What surveyors actually found near you
We read the 123 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Poudre Canyon Rehabilitation And Nursing, Llc | 0 mi | ★★★★★ | 0 | 0 |
| Rehabilitation And Nursing Center Of The Rockies | 0.5 mi | ★★★★★ | 2 | 0 |
| Creekside Village Rehabilitation And Nursing Llc | 0.7 mi | ★★★★★ | 36 | 3 |
| Columbine West Health And Rehab Llc | 2 mi | ★★★★★ | 0 | 0 |
| Centre Avenue Health And Rehab Llc | 2 mi | ★★★★★ | 1 | 0 |
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