Cycle 1
Health 2024-06-11 · Fire 2024-06-11
2 health deficiencies
Top issue: Environmental (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Berthoud, CO
Berthoud Care And Rehabilitation
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
855 Franklin Ave, Berthoud, CO
(970) 532-2683
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
76
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1989-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
0.67
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.84
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,745
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
54.25
Composite VBP score used to determine payment impact.
Payment multiplier
1.0091
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.49
Baseline 18.77% · Performance 19.35% · Measure score 4.49 · Achievement 4.49 · Improvement 0
Healthcare-associated infections
7.89
Baseline 6.23% · Performance 5.48% · Measure score 7.89 · Achievement 7.89 · Improvement 5.59
Total nurse turnover
8.19
Baseline 55.93% · Performance 30.19% · Measure score 8.19 · Achievement 8.19 · Improvement 7.78
Adjusted total nurse staffing
1.13
Baseline 3.25 hours · Performance 3.40 hours · Measure score 1.13 · Achievement 1.13 · Improvement 0.10
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.31% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 5.88% · Lower 95% interval 6.46% |
| Discharge to community | 51.73% |
50.57%
1.2 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 47.46% · Lower 95% interval 43.34% |
| Medicare spending per beneficiary | 1.31 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 90.41% |
95.27%
4.9 pts worse
|
Numerator 66 · Denominator 73 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 73 |
| Discharge self-care score | 61.54% |
53.69%
7.9 pts better
|
Numerator 32 · Denominator 52 |
| Discharge mobility score | 55.77% |
50.94%
4.8 pts better
|
Numerator 29 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 73 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.48% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 0% · Lower 95% interval 2.51% |
| Staff COVID-19 vaccination coverage | 1.06% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 94 |
| Staff flu vaccination coverage | 77.12% |
42%
35.1 pts better
|
Numerator 91 · Denominator 118 |
| Discharge function score | 78.85% |
56.45%
22.4 pts better
|
Numerator 41 · Denominator 52 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 22.86% |
25.2%
2.3 pts worse
|
Numerator 8 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.3
0.5 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.7
0.8 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
93.5%
4.3 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.4% · Q2 100.0% · Q3 100.0% · Q4 98.2% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.8% |
94.7%
9.9 pts worse
|
95.5%
10.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.4%
1.2 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.5% · Q3 0.0% · Q4 1.8% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.9% |
7.4%
9.5 pts worse
|
11.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 19.6% · Q3 14.9% · Q4 9.8% · 4Q avg 16.9% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.0%
1.1 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.8% · Q3 8.0% · Q4 2.0% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.4% |
11.2%
1.2 pts worse
|
19.6%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 11.3% · Q3 13.5% · Q4 17.6% · 4Q avg 12.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
20.6%
3.7 pts better
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 18.6% · Q3 14.3% · Q4 10.6% · 4Q avg 16.9% · 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 | 18.5% |
15.2%
3.3 pts worse
|
16.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 28.1% · Q3 21.1% · Q4 20.5% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.5% |
14.6%
0.9 pts worse
|
14.9%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 24.5% · Q3 15.7% · Q4 12.0% · 4Q avg 15.5% · 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 | 0.4% |
1.5%
1.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.6% |
22.4%
5.2 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.9% · Q2 32.6% · Q3 23.8% · Q4 29.2% · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
3.7%
2.6 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
76.4%
7.5 pts better
|
81.7%
2.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.0% · Q2 80.9% · Q3 88.2% · Q4 84.2% · 4Q avg 83.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.7% |
12.8%
3.1 pts better
|
12.0%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.7% · Observed 11.8% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 3.6% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.4% |
75.6%
4.8 pts better
|
79.7%
0.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.1% |
20.3%
11.8 pts worse
|
23.9%
8.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.1% · Observed 35.3% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-16 · Fire 2023-02-16
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-11-09 · Fire 2021-11-09
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-15
F · Potential for more than minimal harm
2024-06-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-06-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-15
F · Potential for more than minimal harm
2024-06-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-10
F · Potential for more than minimal harm
2024-06-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-15
F · Potential for more than minimal harm
2024-06-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-15
F · Potential for more than minimal harm
2024-06-11
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-08-15
E · Potential for more than minimal harm
2024-06-11
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 2024-08-15
E · Potential for more than minimal harm
2024-06-11
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-08-15
E · Potential for more than minimal harm
2024-06-11
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-06-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-15
F · Potential for more than minimal harm
2023-02-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-04
F · Potential for more than minimal harm
2023-02-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-04
F · Potential for more than minimal harm
2023-02-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-16
F · Potential for more than minimal harm
2021-11-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-26
F · Potential for more than minimal harm
2021-11-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-26
F · Potential for more than minimal harm
2021-11-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-28
F · Potential for more than minimal harm
2021-11-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-06-11
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 2024-07-10
D · Potential for more than minimal harm
2024-06-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-10
F · Potential for more than minimal harm
2023-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-17
E · Potential for more than minimal harm
2023-02-16
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-02-16
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-16
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-03-17
D · Potential for more than minimal harm
2023-02-16
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-03-25
E · Potential for more than minimal harm
2021-11-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-12-08
E · Potential for more than minimal harm
2021-11-09
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 2021-12-08
E · Potential for more than minimal harm
2021-11-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-08
E · Potential for more than minimal harm
2021-11-09
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 2021-12-08
D · Potential for more than minimal harm
2021-11-09
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2021-08-23
D · Potential for more than minimal harm
2021-11-09
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-12-08
D · Potential for more than minimal harm
2021-11-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-12-08
Penalties and ownership
What sits behind the stars
Ownership
Endura Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Fraser, Malcolm
Operational/Managerial Control · Individual
Graham, Joseph
Operational/Managerial Control · Individual
Graham, Joseph
Corporate Officer · Individual
Isomed Inc
Operational/Managerial Control · Organization
Jorgensen, David
Corporate Director · Individual
Keetch, Chad
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
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