Inspection Reports for
Storybrook Care & Rehabilitation
1005 E ELIZABETH ST, FORT COLLINS, CO, 80524-3911
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 22, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to meet professional standards of quality in performing a PICC line dressing change and failure to follow infection prevention and control protocols.
Complaint Details
The complaint investigation found substantiated issues with PICC line dressing procedures and infection control practices, including failure to follow enhanced barrier precautions and lack of staff training.
Findings
The facility failed to ensure professional standards were followed during a PICC line dressing change for Resident #7, including improper sterile technique and lack of training for the nurse involved. Additionally, the facility failed to implement enhanced barrier precautions consistently, as staff did not wear required gowns during high-contact care activities.
Deficiencies (2)
F 0658: The facility failed to ensure professional standards were followed during a PICC line dressing change for Resident #7, including improper sterile technique, leaving the PICC line exposed, and failure to measure catheter length.
F 0880: The facility failed to provide and implement an infection prevention and control program by not ensuring enhanced barrier precautions were followed during PICC line dressing changes and other high-contact care activities.
Report Facts
Residents in sample: 9
Residents affected: 1
Staff experience: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed performing deficient PICC line dressing change and interviewed about lack of training |
| CNA #2 | Certified Nurse Aide | Observed failing to don protective gown during incontinence care for Resident #7 |
| Director of Nursing | Director of Nursing | Interviewed regarding staff training and infection control policies |
| Infection Preventionist | Infection Preventionist and Staff Development Coordinator | Interviewed regarding training and infection control practices |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed about conducting in-house training for PICC line management |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 15, 2025
Visit Reason
The inspection was conducted to investigate allegations of physical abuse between residents and to assess the facility's compliance with care standards following reported incidents.
Complaint Details
The complaint involved an alleged physical abuse incident on 7/23/25 where Resident #3 struck Resident #6. The facility's investigation found no intentional injury but confirmed the strike occurred. The complaint also included concerns about inadequate nursing assessments and monitoring after falls for Residents #7 and #5, with Resident #7 suffering a delayed diagnosis of a subdural hemorrhage.
Findings
The facility failed to prevent physical abuse between residents, specifically Resident #3 striking Resident #6. Additionally, the facility failed to ensure proper nursing assessments and monitoring following falls for Residents #7 and #5, resulting in delayed treatment and actual harm.
Deficiencies (2)
F 0600: The facility failed to protect Resident #6 from physical abuse by Resident #3, despite policies prohibiting abuse and an investigation that could not substantiate intentional harm.
F 0689: The facility failed to ensure Residents #7 and #5 were assessed by a registered nurse following falls, and Resident #7, on anticoagulant medication, was not consistently monitored after hitting her head, resulting in delayed diagnosis of a significant brain hemorrhage.
Report Facts
Residents reviewed for quality of care: 7
Residents sample size: 10
BIMS score: 5
BIMS score: 0
BIMS score: 9
Fall date: 2025
Subdural hemorrhage size: 17
Midline shift: 11
Resident #5 fall date: 2025
Resident #5 forehead gash size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed regarding the physical abuse incident and fall assessments. |
| RN #2 | Registered Nurse | Interviewed regarding fall assessments and facility procedures. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding fall assessments and documented care for Resident #5. |
| CNA-Med #1 | Certified Nurse Aide with Medication Authority | Interviewed regarding reporting falls and resident assessments. |
| NHA | Nursing Home Administrator | Interviewed regarding abuse investigation and fall assessment policies. |
| DON | Director of Nursing | Interviewed regarding fall assessments and facility policies. |
Inspection Report
Routine
Census: 52
Deficiencies: 2
Date: Jun 3, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding resident care environment, specifically focusing on cleanliness and availability of linens.
Findings
The facility failed to provide a safe, clean, and comfortable environment by not ensuring enough clean linens were available and by failing to maintain clean floors in residents' rooms, hallways, and the main dining room.
Deficiencies (2)
F 0584: The facility failed to ensure there were enough clean linens, resulting in residents missing showers and bed baths due to linen shortages. The laundry staff lacked education on proper linen cleaning and disposal.
F 0584: The facility failed to maintain clean floors in residents' rooms, hallways, and the main dining room, with observations of dried liquid spots, debris, food and beverage spills, and wheelchair tracks.
Report Facts
Facility census: 52
Linen stock counts: 0
Housekeepers count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified nurse aide #1 | CNA | Interviewed regarding linen shortages and resident care impact |
| Laundry aide #1 | LA | Interviewed regarding linen inventory and ordering |
| Maintenance supervisor | MS | Interviewed regarding linen disposal and cleaning staff |
| Director of nursing | DON | Interviewed regarding awareness of linen shortages and staff education |
| Nursing home administrator | NHA | Interviewed regarding linen supply management and staff coordination |
| Housekeeper #1 | HK | Interviewed regarding cleaning schedules and staffing |
Inspection Report
Routine
Deficiencies: 10
Date: Sep 19, 2024
Visit Reason
Routine inspection of Storybrook Care & Rehabilitation to assess compliance with regulatory requirements including resident rights, grievance policies, PASRR coordination, pressure ulcer care, dental services, food quality, food preferences, food safety, and facility environment.
Findings
The facility failed to ensure resident council meetings were conducted without staff presence and failed to provide timely responses to resident grievances. The facility did not incorporate PASRR level II recommendations into care planning for one resident. One resident developed a facility-acquired pressure injury due to inconsistent implementation of offloading boots. The facility failed to assist three residents in obtaining timely dental services. Food served was often unpalatable and did not meet resident preferences, especially for vegetarian and diabetic diets. Food safety violations included improper labeling, storage, and unclean kitchen equipment. Staff failed to perform appropriate hand hygiene during meal service. The laundry room environment was unsanitary and unsafe.
Deficiencies (10)
F 0565: The facility failed to allow resident council meetings without staff present, provide private meeting space, and respond adequately to food concerns raised by residents.
F 0572: The facility failed to provide ongoing communication about resident rights and responsibilities both orally and in writing.
F 0585: The facility failed to establish a grievance policy that ensured residents had information on how to file grievances and failed to resolve grievances related to lost/stolen items.
F 0644: The facility failed to incorporate PASRR level II recommendations into assessment, care planning, and service provision for one resident.
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident, including inconsistent use of offloading boots and delayed wound care interventions.
F 0791: The facility failed to assist three residents in obtaining routine or emergency dental services and failed to replace dentures in a timely manner.
F 0804: The facility failed to consistently serve food that was palatable, attractive, and at the appropriate temperature.
F 0806: The facility failed to provide food that accommodated resident allergies, intolerances, and preferences for three residents.
F 0812: The facility failed to store, prepare, distribute and serve food in a sanitary manner, including improper food labeling, food stored on the floor, unclean kitchen equipment, and failure of staff to perform appropriate hand hygiene during meal service.
F 0921: The facility failed to provide a safe, functional, sanitary and comfortable environment in the laundry room, including clean slings hanging in the dirty laundry room, damaged ceiling, and a door that could not close.
Report Facts
Residents interviewed in group: 5
Resident sample size: 19
Pressure ulcer size: 3.5
BIMS scores: 3
BIMS scores: 10
BIMS scores: 12
BIMS scores: 13
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Named in relation to food quality, food preferences, and food safety deficiencies |
| Nursing Home Administrator | Nursing Home Administrator | Named in relation to resident council and grievance findings |
| Regional Clinical Resource | Regional Clinical Resource | Named in relation to PASRR, grievance, and infection prevention interviews |
| Registered Nurse #2 | Registered Nurse | Named in relation to pressure ulcer care and dental services |
| Certified Nurse Aide #1 | Certified Nurse Aide | Named in relation to grievance and dental services |
| Certified Nurse Aide #2 | Certified Nurse Aide | Named in relation to grievance, dental services, and food service observations |
| Activities Director | Activities Director | Named in relation to resident council coordination |
| Director of Housekeeping | Director of Housekeeping | Named in relation to laundry room environmental concerns |
Inspection Report
Deficiencies: 1
Date: Apr 11, 2023
Visit Reason
The inspection was conducted to evaluate compliance with meal service and snack provision policies at the nursing home.
Findings
The facility failed to ensure residents received meals in a timely manner and did not offer nourishing snacks at bedtime. Specifically, there was more than 14 hours between the evening meal and breakfast without a nourishing snack, and snacks were not routinely offered or available to residents.
Deficiencies (1)
F 0809: The facility failed to ensure meals and snacks were served according to residents' needs and preferences. There was more than 14 hours between the evening meal and breakfast without a nourishing bedtime snack.
Report Facts
Meal interval hours: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding snack offerings and medication administration record | |
| Dietary Manager | Interviewed regarding snack availability and offerings | |
| Director of Nursing (DON) | Interviewed regarding snack policies and resident risk identification |
Inspection Report
Re-Inspection
Deficiencies: 14
Date: Apr 11, 2023
Visit Reason
Re-inspection survey to verify correction of previously cited deficiencies related to resident care, safety, nutrition, medication management, food service, infection control, and staff training.
Findings
The facility demonstrated multiple ongoing deficiencies including failure to provide a clean and safe environment, inadequate assistance with activities of daily living, improper management of hearing aids, failure to prevent resident falls and weight loss, ineffective pain management, improper food preparation and storage, lack of psychotropic medication monitoring, incomplete infection control program, and insufficient staff training.
Deficiencies (14)
F0584: Facility failed to provide a clean, safe, homelike environment by improperly storing medical equipment in resident areas.
F0677: Facility failed to provide scheduled assistance with showers for Resident #12, resulting in inadequate personal hygiene.
F0685: Facility failed to provide assistance with hearing aids and ensure safe storage for Resident #7.
F0689: Facility failed to prevent falls for Resident #30, resulting in multiple falls and a hip fracture.
F0692: Facility failed to provide adequate nutritional support and meal assistance for Resident #30, resulting in significant weight loss.
F0697: Facility failed to provide effective pain management for Resident #10 during wound care, resulting in severe pain and refusal of care.
F0700: Facility failed to assess and maintain bed cane/bed rail safety for Resident #12, including lack of monthly inspections and proper consent.
F0758: Facility failed to ensure psychotropic medications were appropriately monitored, consented, and managed for Resident #247.
F0805: Facility failed to prepare food according to diet orders, serving whole dinner rolls instead of slurried rolls for residents on mechanical dysphagia level 2 diet.
F0812: Facility failed to ensure proper hand hygiene and glove use by dietary staff and failed to maintain sanitary food storage in unit refrigerators.
F0813: Facility failed to maintain appropriate temperatures and sanitary conditions in resident refrigerators, including expired foods and improper food storage.
F0867: Facility failed to implement an effective quality assurance program to address repeat deficiencies and ensure systemic improvements.
F0880: Facility failed to implement a water management program to prevent Legionella growth and spread in building water systems.
F0947: Facility failed to provide required annual training hours and abuse prevention education to certified nurse aides.
Report Facts
Deficiencies cited: 15
Resident sample size: 28
Psychotropic medication doses: 23
Weight loss percentage: 10.4
Temperature readings: 42
Training hours: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Interviewed regarding cleaning of medical equipment and resident care. |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple care and compliance issues. |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding resident care and pain management. |
| Dietary Manager | Dietary Manager | Interviewed regarding food service and storage practices. |
| Nursing Home Administrator | NHA | Interviewed regarding facility policies and quality assurance. |
| Registered Nurse #1 | RN | Interviewed regarding medication administration and resident care. |
| Director of Therapy Services | Director of Therapy Services | Interviewed regarding bed cane assessments and resident mobility. |
Inspection Report
Deficiencies: 5
Date: Jan 18, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, environment, activities, and psychotropic medication use at Storybrook Care & Rehabilitation.
Findings
The facility was found deficient in maintaining a safe, clean, and comfortable environment in resident rooms, developing and implementing comprehensive care plans for medication management, providing consistent assistance with activities of daily living such as showers, offering meaningful activities in the memory care unit, and ensuring proper consent, monitoring, and pharmacist recommendations for psychotropic medication use.
Deficiencies (5)
F 0584: The facility failed to maintain six resident rooms in a safe, clean, and comfortable condition, with issues such as broken blinds, chipped paint, damaged walls, and unclean floors.
F 0656: The facility failed to develop and implement a comprehensive care plan with measurable objectives for Resident #30's use of anticoagulant, antidiabetic, and hypertensive medications.
F 0677: The facility failed to provide regular and consistent showers according to preferences and care plans for five residents, citing staffing shortages as a cause.
F 0679: The facility failed to provide ongoing activities tailored to the interests and needs of residents in the memory care unit, with no documented participation or scheduled activities.
F 0758: The facility failed to obtain consent, track behaviors, and follow pharmacist recommendations for psychotropic medications for four residents, lacking specific care plans and behavior monitoring.
Report Facts
Residents affected: 6
Residents affected: 5
Residents affected: 4
Residents affected: 4
Residents affected: 1
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