Cycle 1
Health 2024-09-19 · Fire 2024-09-19
15 health deficiencies
Top issue: Resident Rights (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fort Collins, CO
Storybrook Care & Rehabilitation
2-star overall rating with 1-star inspections with $98,959 in total fines with 15 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1005 E Elizabeth St, Fort Collins, CO
(970) 482-2525
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sweetwater Care
Operator or chain grouping
Approved since
1989-05-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 3 overall / 2 health / 2 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
0.63
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.08
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.57
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,007
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.77
Composite VBP score used to determine payment impact.
Payment multiplier
0.9947
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.96
Baseline 100.00% · Performance 58.97% · Measure score 4.96 · Achievement 1.15 · Improvement 4.96
Adjusted total nurse staffing
3.39
Baseline 4 hours · Performance 4.04 hours · Measure score 3.39 · Achievement 3.39 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 18 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.29% |
8.2%
3.9 pts worse
|
Numerator 3 · Denominator 70 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.3 |
1.3
1 pts better
|
1.9
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 79.5% |
93.5%
14 pts worse
|
93.4%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 55.3% · Q2 70.7% · Q3 86.0% · Q4 100.0% · 4Q avg 79.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.3% |
94.7%
0.6 pts better
|
95.5%
0.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.4%
1.3 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.4% · Q3 4.7% · Q4 8.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 22.0% |
7.4%
14.6 pts worse
|
11.4%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 12.5% · Q3 28.6% · Q4 38.3% · 4Q avg 22.0% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.0%
2 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 13.9% · Q3 11.8% · Q4 2.6% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.5% |
11.2%
7.3 pts worse
|
19.6%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 16.2% · Q3 22.9% · Q4 12.5% · 4Q avg 18.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.2% |
20.6%
15.6 pts worse
|
16.7%
19.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.3% · Q2 37.0% · Q3 26.1% · Q4 37.9% · 4Q avg 36.2% · 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 | 8.2% |
15.2%
7 pts better
|
16.3%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 19.1% · Q3 8.7% · Q4 0.0% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
14.6%
0.6 pts worse
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 28.6% · Q3 11.8% · Q4 13.2% · 4Q avg 15.2% · 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 | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 13.5% |
22.4%
8.9 pts better
|
19.8%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 19.4% · Q3 12.9% · Q4 13.8% · 4Q avg 13.5% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
3.7%
2.8 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.1% |
76.4%
3.7 pts better
|
81.7%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 66.7% · Q3 87.0% · Q4 100.0% · 4Q avg 80.1% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.5%
1.3 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 4.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.1% |
75.6%
0.5 pts better
|
79.7%
3.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-11 · Fire 2023-04-11
14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-01-18 · Fire 2022-01-18
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-12
F · Potential for more than minimal harm
2024-09-19
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-11-05
F · Potential for more than minimal harm
2024-09-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-05
F · Potential for more than minimal harm
2024-09-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-07
F · Potential for more than minimal harm
2024-09-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-03
F · Potential for more than minimal harm
2024-09-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-18
F · Potential for more than minimal harm
2024-09-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-30
F · Potential for more than minimal harm
2023-04-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-10
F · Potential for more than minimal harm
2023-04-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-08
F · Potential for more than minimal harm
2022-01-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-02-25
D · Potential for more than minimal harm
2022-01-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-02-23
D · Potential for more than minimal harm
2022-01-18
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-03-11
D · Potential for more than minimal harm
2022-01-18
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-02-24
D · Potential for more than minimal harm
2022-01-18
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 2022-03-11
D · Potential for more than minimal harm
2022-01-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-22
D · Potential for more than minimal harm
2022-01-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-12-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-23
G · Actual harm
2025-10-15
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 2025-10-16
D · Potential for more than minimal harm
2025-10-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-16
E · Potential for more than minimal harm
2025-06-03
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-04
G · Actual harm
2024-09-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-13
E · Potential for more than minimal harm
2024-09-19
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-10-13
E · Potential for more than minimal harm
2024-09-19
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2024-10-13
E · Potential for more than minimal harm
2024-09-19
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 2024-10-13
E · Potential for more than minimal harm
2024-09-19
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-10-13
E · Potential for more than minimal harm
2024-09-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-10-13
E · Potential for more than minimal harm
2024-09-19
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-10-13
E · Potential for more than minimal harm
2024-09-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-13
D · Potential for more than minimal harm
2024-09-19
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-10-13
D · Potential for more than minimal harm
2024-09-19
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-10-13
G · Actual harm
2023-04-11
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 2023-07-10
G · Actual harm
2023-04-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-10
G · Actual harm
2023-04-11
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-07-10
F · Potential for more than minimal harm
2023-04-11
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-07-10
F · Potential for more than minimal harm
2023-04-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-10
F · Potential for more than minimal harm
2023-04-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-07-07
F · Potential for more than minimal harm
2023-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-04-11
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-04-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-10
E · Potential for more than minimal harm
2023-04-11
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-07-10
E · Potential for more than minimal harm
2023-04-11
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-11
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-04-11
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-05-12
E · Potential for more than minimal harm
2022-01-18
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-02-25
E · Potential for more than minimal harm
2022-01-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-02-25
E · Potential for more than minimal harm
2022-01-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-02-25
E · Potential for more than minimal harm
2022-01-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-02-25
D · Potential for more than minimal harm
2022-01-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-02-25
Penalties and ownership
What sits behind the stars
$6,666
2025-10-15
Fine
Fine · fine $6,666
Fine
$31,847
2024-09-19
Fine
Fine · fine $31,847
Fine
$60,446
2023-04-11
Fine
Fine · fine $60,446
Fine
Ownership
Chesley, Aaron
5% Or Greater Indirect Ownership Interest · Individual
Chesley, Aaron
Operational/Managerial Control · Individual
Gamett, James
General Partnership Interest · Individual
Gamett, James
Operational/Managerial Control · Individual
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#3
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