Storybrook Care & Rehabilitation

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

for RN #1 was reviewed on 12/22/25 at 4:15 p.m. RN #1's employee file did not contain documentation that

he had completed training and competency to show he was able to demonstrate skills and techniques necessary to perform an appropriate PICC line dressing change.IV. Staff interviews RN #1 was interviewed

on 12/22/25 at 2:17 p.m. RN #1 said he had worked at the facility for less than two months. RN #1 said he had experience with changing PICC line dressings from his previous employment. RN #1 said he had not received any formal training on PICC line dressing changes from the current facility. RN #1 said he would like education and training from the facility. RN #1 said he was nervous while performing Resident #7's PICC line dressing change and that is the reason he failed to complete the procedure in the appropriate steps (see observation above). RN #1 said he knew that he was not supposed to leave the resident's PICC line exposed and instead should have used the call bell to request other staff members to bring him additional supplies. The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 12/22/25 at 3:47 p.m. The IP said he also performed the role of the staff development coordinator and was in charge of nursing training. The IP said the facility was in the process of initiating a new training platform for all nursing staff. The IP said competency training had not yet started on the new training platform. The IP said the manner in which RN #1 completed the PICC line dressing change for Resident #7 was not the standard of care. The IP said it was important to follow the standard of care to prevent infections, protect resident safety and promote consistent high quality care. The DON said she had two nurses currently working in the facility. The DON said neither of the nurses had received training for PICC line management. The DON said all nursing staff should be properly trained and demonstrate competency for nursing skills tasks prior to performing resident care. The DON said this was important to maintain resident safety and ensure professional and reliable healthcare practices.The regional nurse consultant was interviewed on 12/22/25 at 4:18 p.m. The regional nurse consultant said she would conduct in-house training for PICC line management for nursing staff starting that day (12/22/25).

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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

12/22/2025

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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

said the nurses were really nice but they never wore gowns or a mask when giving him his IV antibiotics. He said he was unsure if there were any requirements for the nurses to wear gowns or masks when he would get his IV medication. On 12/22/25 at 1:14 p.m. registered nurse (RN) #1 was observed performing a PICC line dressing change for Resident #7. -RN #1 wore gloves and a mask during Resident #7's PICC line dressing change, however RN #1 failed to don a protective gown during the PICC line dressing change. On 12/22/25 at 1:45 p.m. certified nurse aide (CNA) #2 was assisting Resident #7 with transferring from his wheelchair to the private toilet in his room. -However, CNA #2 failed to put on a protective gown prior to providing incontinence care to Resident #7.IV. Staff interviews CNA #2 was interviewed on 12/22/25 at 2:08 p.m. CNA #2 said Resident #7 needed staff assistance to get out of his bed into his wheelchair and from his wheelchair onto the toilet. She said Resident #7 was on EBP because of his IV line. She said there were no special precautions for her because she did not have to do any care with his IV line. She said she only needed to wear gloves when assisting the resident with personal care. RN #1 was interviewed on 12/22/25 at 2:30 p.m. RN #1 said he had worked at the facility for less than two months. RN #1 said he forgot to don

a gown when he was changing Resident #7's PICC line (see observation above) because he was focused

on the dressing change. RN #1 said he should have had a gown, gloves and mask on to protect the resident from acquiring an infection from the dressing change.The DON and the infection preventionist (IP) were interviewed together on 12/22/25 at 3:47 p.m. The IP said he also performed the role of the staff development coordinator and was in charge of nursing training. The IP said all of the facility nursing staff were trained on enhanced barrier precautions. The IP said CNA #2 should have donned a gown and gloves prior to assisting Resident #7 with the chair to toilet transfer. The IP said RN #1 was required to don a gown along with a mask and gloves while performing PICC line care for Resident #7. The IP said he would conduct reeducation on EBP for both RN #1 and CNA #2. The DON said RN #1 and CNA #2 should have followed the precaution requirements for EBP when providing direct care for Resident #7, which included wearing gowns and gloves with high-contact resident activity.

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