Federal inspection record · CMS data as of October 1, 2026
Berthoud Care And Rehabilitation
855 Franklin Ave, Berthoud, CO · (970) 532-2683
- Certified beds
- 76
- Residents per day
- 64
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- October 1, 1989
1
How this home got 4 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Colorado.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★4 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Colorado homes
Berthoud Care And Rehabilitation carries 42 inspection points. That is fewer than 68% of Colorado's 208 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Colorado: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–22 pts
- 4★ 22–44 pts
- 3★ 44–70.75 pts
- 2★ 70.75–104 pts
- 1★ over 104 pts
Bars show every rated home in Colorado by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
16 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care6E
- E
Provide activities to meet all resident's needs.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide or obtain dental services for each resident.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide activities to meet all resident's needs.
- D
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.
Infection Control2F
- E
Provide and implement an infection prevention and control program.
- F
Provide and implement an infection prevention and control program.
Administration1F
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Resident Rights1D
- D
Keep residents' personal and medical records private and confidential.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Protect each resident from the wrongful use of the resident's belongings or money.
Environmental1E
- E
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Nursing and Physician Services1E
- E
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.
Resident Assessment and Care Planning1D
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Pharmacy Service1D
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Nutrition and Dietary1D
- D
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.
Inspection history
2026-06-02
7 health deficiencies · 5 fire-safety deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2024-06-11
2 health deficiencies · 11 fire-safety deficiencies
Top issue: Environmental (1 deficiency)
2023-02-16
7 health deficiencies · 3 fire-safety deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 18 min of nursing staff time a day, 47 min of it from a registered nurse.
This home
3 h 18 min
Colorado average
3 h 42 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.7 pts worse | 2.1 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.8 pts worse | 2.5 | 1.7 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine5.7 pts better | 99.1% | 93.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.1 pts better | 94.8% | 93.7% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.6 pts better | 2.8% | 3.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms0.5 pts better | 8.3% | 8.8% | 13.5% |
| Percentage of long-stay residents who lose too much weight3.8 pts better | 1.0% | 4.8% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication3.5 pts better | 8.1% | 11.6% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication4.6 pts better | 15.3% | 19.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened9.7 pts worse | 21.4% | 11.7% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased6.5 pts worse | 19.3% | 12.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.5 pts better | 0.0% | 0.5% | 0.7% |
| Percentage of long-stay residents with a urinary tract infectionAbout the same | 1.4% | 1.4% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence5.2 pts worse | 25.8% | 20.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.5 pts better | 1.9% | 3.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine12.8 pts better | 89.8% | 77.0% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit1.8 pts worse | 13.8% | 12.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.2 pts better | 1.4% | 1.6% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine10.5 pts better | 84.1% | 73.6% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission8.9 pts worse | 29.4% | 20.5% | 23.4% |
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Who owns and runs it
15 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Fraser, Malcolm | Managing Control - Governing Body · Individual | 0% | 6 facilities |
| Fraser, Malcolm | Operational/Managerial Control · Individual | 0% | 6 facilities |
| Fraser, Malcolm | Adp Of The SNF · Individual | 0% | 6 facilities |
| Graham, Joseph | Managing Control - Governing Body · Individual | 0% | 15 facilities |
| Graham, Joseph | Corporate Officer · Individual | 0% | 15 facilities |
| Graham, Joseph | Operational/Managerial Control · Individual | 0% | 15 facilities |
| Graham, Joseph | Adp Of The SNF · Individual | 0% | 15 facilities |
| Isomed Inc | Operational/Managerial Control · Organization | 0% | 2 facilities |
| Jorgensen, David | Corporate Director · Individual | 0% | 56 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Port, Barry | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 203 facilities |
| Sato, Ami | Corporate Officer · Individual | 0% | 151 facilities |
| Smv Berthoud LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
·
Fire safety
19 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke10F
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Inspect, test, and maintain automatic sprinkler systems.
- F
Provide properly protected cooking facilities.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
- E
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
- F
Provide properly protected cooking facilities.
- F
Inspect, test, and maintain automatic sprinkler systems.
Services3F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Gas, Vacuum, and Electrical Systems2F
- E
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Egress2F
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E
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.
Construction1F
- F
Use approved construction type or materials.
Miscellaneous1D
- D
Have simulated fire drills held at unexpected times.
·
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