Storybrook Care & Rehabilitation

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident #6 - victim1. Resident statusResident #6, age greater than 65, was admitted on [DATE REDACTED]. According to the October 2025 CPO, diagnoses included senile degeneration of the brain, dementia with agitation and adult failure to thrive. The 10/3/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15 and had no behaviors. The resident was dependent on staff for toileting, showering, upper body dressing, lower body dressing, personal hygiene and putting on/taking off footwear.2. Record reviewThe behavior care plan, revised on 10/30/24, revealed at times the resident could display behaviors that included cursing at all persons within her immediate vicinity, hitting during activities, hitting during cares, kicking, shouting, screaming and the refusal of care. The care plan documented at times, the resident ran into others with her wheelchair as she ambulated down the hall and the resident prevented others from coming around the area in front of her room entrance or going into her room. The interventions included attempting interventions before the behaviors began, staff were not to position the resident near others that disturbed the resident, positioning the resident in her favorite place to sit, helping help the resident avoid situations or others that upset the resident, notifying the resident's physician if her behaviors were interfering with her activities of daily living, offering diversional activities and reporting to her physician as appropriate, telling the resident what was going to happen before the activity/care was initiated and speaking with the resident unhurriedly and in a calm voice.The care plan for elopement risk/wandering, revised on 10/30/24 revealed Resident #6 was at risk for elopement related to impaired safety awareness and dementia. The interventions included staff were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and/or a book.The care plan for secure unit placement, initiated on 10/10/25, revealed Resident #6 was an elopement risk. The care plan documented the resident was disoriented to place, had a history of attempts to leave the facility unattended, had impaired safety awareness and wandered aimlessly. The interventions included distracting

the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and/or a book, the resident liked drinking coffee with pastry and enjoyed dolls, identifying the patterns and triggers of wandering tendencies, understanding the resident's triggers for wandering/elopement and the methods for de-escalation the resident.On 10/14 25 at approximately 3:00 p.m. the resident's electronic medical record (EMR) was reviewed. -The EMR did not contain progress notes related to the physical altercation with Resident #3 on 7/23/25.III. Staff interviewsRN #3 was interviewed on 10/14/25 at 11:27 a.m. RN #3 said she remembered the event that occurred on 7/23/25. RN #3 said Resident #3 hit Resident #6 on the upper arm. She said the residents were in the dining room area and she did not know what caused the altercation. RN #3 said the residents might have been too close to each other and Resident #3 was agitated at the time of the altercation. RN #3 said she assessed Resident #6. RN #3 said neither resident said they were afraid of each other at that time.The NHA and the director of nursing (DON) were interviewed together on 10/14/25 at 3:35 p.m. The NHA and the DON agreed with the documentation in the residents' medical records and on the investigation reports. The NHA was unable to provide any skin assessments for Resident #6.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Storybrook Care & Rehabilitation

1005 E Elizabeth St Fort Collins, CO 80524

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited STORYBROOK CARE & REHABILITATION in FORT COLLINS, CO for a deficiency under regulatory tag F-F0689 during a complaint investigation conducted on 2025-10-15.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope/Severity Level G: isolated, actual harm that is not immediate jeopardy.

Actual harm to residents was documented as a result of this deficiency.

This was one of 2 deficiencies cited during this inspection of STORYBROOK CARE & REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-16.