Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Berthoud Care And Rehabilitation during CMS and state inspections, most recent first.
PBJ staffing data was not successfully submitted to CMS because the file was rejected due to a coding error tied to employee position coding. Although the facility submitted the report before the deadline, it did not recognize the rejection until after the deadline had passed, and the issue was linked to a payroll system change that affected the data file.
Weekend activities were not consistently provided to meet residents’ needs. Residents said weekends were boring, with little to do besides sit in rooms or hallways, and one resident reported having to call bingo numbers himself because the sole weekend activity aide had left and was not replaced. Staff interviews showed activity staff worked weekdays only, no activity staff were scheduled on weekends, and the receptionist had front desk duties that limited her ability to run activities. The facility also did not provide the requested weekend activity participation logs.
Oxygen flow rates were not kept consistent with physician orders for three residents receiving O2 therapy. One resident with CHF and other chronic conditions was observed on 3 LPM despite an order for 2 LPM continuous. Another resident with chronic respiratory failure and dementia had an order for 1 LPM continuous, but the care plan directed 2 LPM and the resident reported staff had set the flow as high as 3.5 LPM. A third resident with COPD and chronic respiratory failure was observed at 3.5 to 4 LPM despite an order for 3 LPM every shift, and staff acknowledged the resident sometimes changed the setting herself.
Infection control failed when a housekeeper cleaned a resident bathroom and handled her cart, mop bucket, and mop heads without changing gloves or performing hand hygiene after cleaning the toilet. Two shower rooms had missing drain covers, leaving open holes in the floor. Two soiled utility rooms also had infection control issues, including a large pile of filled biohazard trash bags and a hopper with water and visible green and brown film.
A cognitively intact resident with multiple chronic diagnoses reported that incoming mail, including a letter from SSA, was delivered already opened on two occasions. The BOM said she accidentally opened the resident’s mail after it was sorted by the front office receptionist and then handed the opened envelope to the resident. The NHA said he had just learned of the concern and believed the mail was opened by accident.
Misappropriation of Resident Property: A resident with dementia and moderate cognitive impairment had a credit card used for unauthorized purchases and about $100 in cash missing from a wallet kept in an unlocked cupboard. Investigation and law enforcement video reportedly identified a CNA using the resident’s card during a store transaction, and the resident’s care plan already noted risk for financial exploitation due to impaired judgment and inability to manage finances safely.
A resident with COPD, chronic respiratory failure, emphysema, depression, heart failure, and moderate cognitive impairment had a broken upper front tooth that was sharp, sometimes painful, and made eating harder. Although a physician documented the broken tooth and recommended dental follow-up, the record did not show a dental appointment was arranged at that time, and the DON and SSD said staff were not aware of the issue until later.
The facility failed to maintain a safe and sanitary environment, with issues in the laundry and soiled utility rooms. The laundry area had a broken exhaust fan, structural damage, and improper storage of clean items near soiled ones. In the soiled utility room, clean items were stored next to dirty linen, and a leaking ceiling was observed. The maintenance supervisor was unaware of these issues, and the infection preventionist confirmed improper storage practices.
The facility failed to follow physician orders for edema care for two residents. One resident did not have elastic hose stockings applied and removed as ordered, with staff misunderstanding and incorrect documentation noted. Another resident's edema monitoring was not documented correctly, with staff using check marks instead of required symbols. Interviews revealed that the resident often declined leg elevation, and supplemental monitoring was not completed. The DON acknowledged the issues and planned staff education.
PBJ Staffing Data Submission Rejected Due to Coding Error
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system for the quarter covering 10/1/25 to 12/31/25. Record review showed the required PBJ data was not submitted for that quarter, and the submission was later found to have been rejected because of an unrecognized coding error attached to employee positions within the file. Interviews confirmed the facility submitted the PBJ file before the deadline, but CMS rejected it shortly after submission and the facility did not recognize the rejection until after the deadline had passed. The operations resource stated the facility’s payroll system changed in January 2026, which led to the coding error that was not identified before submission. The NHA also confirmed the submission had been rejected due to an issue with the data submitted.
Weekend Activities Not Consistently Provided
Penalty
Summary
The facility failed to ensure an ongoing program of meaningful, structured activities was consistently provided on weekends to meet residents’ interests and physical, mental, and psychosocial well-being. The facility policy stated that residents have the right to choose activities and social events and that daily activities, including weekends and holidays, are to be provided. However, the weekend activity calendars for April and May 2026 showed a limited schedule of recurring activities such as daily chronicles, puzzles, bingo, devotional services, church service, snack or drink carts, coloring pages, current events, friendly visits, and occasional movie or affirmation activities. During a group interview, five alert and oriented residents said weekends were long and boring and that there was nothing to do except sit in their rooms or the hallway. One resident said activity staff left on Friday afternoon and did not return until Monday morning, and that the sole weekend activity assistant had left employment on 1/1/26 and had not been replaced. That resident also said he sometimes had to call the numbers for bingo himself so residents could have a bingo game on Saturdays and Sundays. The other residents agreed that the lack of weekend activity staff affected whether the scheduled activities on the calendar actually occurred, and a recently admitted resident also reported a lack of meaningful weekend activities. Staff interviews supported the residents’ reports. Two activity staff members said they worked Monday through Friday and that both available activity staff were off on weekends, while a new staff member said there was no activity staff scheduled for the weekend. The receptionist said she was responsible for front desk duties on Sundays and also assisted with some activities, but struggled to complete all activities because of her front desk responsibilities and sometimes relied on residents to engage in activities without a staff member. The NHA said the front desk staff supported weekend activities and was unaware that a resident felt obligated to run bingo on weekends. The facility also failed to provide the requested weekend activity participation logs for April and May 2026, despite the NHA stating he would provide the last three months of logs.
Oxygen flow rates were not kept consistent with physician orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with physician orders for three residents who were receiving oxygen therapy. The report states that oxygen was treated as a medication and that staff were expected to follow the ordered flow rates, verify oxygen settings on their shifts, and document any changes in flow rate and the rationale for those changes in the EMR. For one resident with critical illness myopathy, CHF, HTN, anxiety, depression, restlessness, and agitation, the physician ordered oxygen by nasal cannula at 2 LPM continuously to keep saturation above 90%. However, observations on multiple occasions showed the oxygen concentrator set at 3 LPM. The resident said she did not know the liter flow she was receiving and could not reach the concentrator, stating that staff managed the oxygen flow. The record showed oxygen saturations ranging from 93% to 99% on 3 LPM, but there was no documentation indicating the resident needed more oxygen based on those saturations. For another resident with DM2 with nephropathy, depression, chronic respiratory failure with hypoxia, dementia, and weakness, the physician order was for 1 LPM continuous oxygen via nasal cannula to keep saturation at or above 90%, yet the care plan directed staff to administer oxygen at 2 LPM continuously. Observations showed the oxygen set at 2 LPM, and the resident reported that staff had previously set the oxygen at 3.5 LPM despite her telling them not to tamper with the flow. The record included oxygen saturations of 98% to 100% on 1 to 2 LPM, but there was no documentation indicating the resident needed more oxygen based on those readings. For a third resident with COPD, chronic respiratory failure, emphysema, depression, and heart failure, the physician ordered oxygen at 3 LPM every shift. Observations showed the concentrator set at 3.5 LPM on several occasions and then at 4 LPM, including an instance where a CNA observed the setting at 4 LPM and informed an RN, who told the CNA not to change the setting at that time. The resident stated she sometimes turned the oxygen up herself and told staff when she did. The record also showed the care plan noted the resident chronically self-adjusted oxygen and was noncompliant with orders, but no additional interventions were included.
Infection Control Lapses in Housekeeping, Shower Rooms, and Soiled Utility Areas
Penalty
Summary
The facility failed to maintain an infection control program on one unit, in two shower rooms, and in two soiled utility rooms. During observation, a housekeeper cleaned a resident bathroom, including the toilet, and then handled her cart, dirty rag, mop bucket, and mop heads without changing gloves or performing hand hygiene. The housekeeper stated she had not been taught to change her gloves after cleaning the toilet and acknowledged she probably should have changed them. The infection preventionist stated the housekeeper should have changed her gloves after cleaning the toilet. During a facility tour, two shower rooms were observed with missing drain covers, leaving approximately three-inch-wide holes in the floor. The housekeeping supervisor said she was unsure why the drain covers were missing or how long they had been missing, and the infection preventionist stated the drains should be covered. In two soiled utility rooms, one contained a large pile of filled red biohazard trash bags on the floor and additional filled bags on the counter, with at least 10 bags present after the biohazard company did not come the previous week. The other soiled utility room had a hopper with water in the bowl and thick green and brown film. The housekeeping supervisor said the bags should not have been piled up, the maintenance director said he was aware the hopper was dirty, and the infection preventionist stated the hopper should be cleaned and maintained.
Opened Resident Mail Delivered Before Privacy Was Preserved
Penalty
Summary
The facility failed to protect a cognitively intact resident’s right to privacy in written communications when incoming mail was delivered already opened. Resident #15, who had diagnoses including an iliac artery aneurysm, acquired absence of the right foot, type 2 diabetes mellitus without complications, and adjustment disorder with mixed anxiety and depressed mood, reported that his mail had been opened on two separate occasions before it was given to him. He stated that one of the opened letters was from the Social Security Administration and that it was handed to him by the business office manager in an opened envelope. The business office manager stated that the front office receptionist received and sorted incoming mail before it was transferred to her, and that she accidentally opened the resident’s Social Security Administration letter before realizing it belonged to a resident. She then delivered the opened mail to the resident and acknowledged that she should have checked the envelope before opening it. She also stated that she did not report the incident to the NHA, while the NHA stated he had just been informed of the concern and believed the mail had been opened by accident.
Misappropriation of Resident Property
Penalty
Summary
The facility failed to prevent misappropriation of a resident’s property when a staff member stole the resident’s credit card and cash. Resident #42 had diagnoses including diabetes, COPD, dementia, and generalized muscle weakness, and the 4/15/26 MDS showed moderate cognitive impairment with a BIMS score of 8 out of 15. The resident also required substantial assistance with personal care and bathing and had impaired hearing with hearing aids. The resident’s representative reported that unauthorized credit card charges were discovered on the resident’s statement, with transactions occurring between 4/30/26 and 5/8/26 at gas stations and convenience stores totaling $224.47. The representative also reported that approximately $100.00 in cash was missing from the resident’s wallet, which had been kept in an unlocked cupboard in the resident’s room. The resident’s representative stated the resident had poor short-term memory and did not remember the incident. The facility’s investigation identified CNA #2 as the staff member involved. The investigation noted that CNA #2 may have provided care to the resident on 4/28/26, 4/29/26, and/or 4/30/26, and law enforcement later provided video footage reportedly showing CNA #2 using the resident’s credit card during a store transaction. The resident’s care plan already identified her as at risk for financial exploitation or misappropriation because of cognitive impairment, intermittent confusion, impaired judgment, and inability to manage finances safely.
Failure to Arrange Timely Dental Care for a Resident With a Broken Tooth
Penalty
Summary
The facility failed to ensure timely dental services for one resident reviewed for ancillary services. Resident #29, who had COPD, chronic respiratory failure, emphysema, depression, heart failure, and moderate cognitive impairment, had a broken upper left front tooth with a jagged edge. During observation, the resident said the tooth had been broken for months, sometimes caused mouth pain, and made it more difficult to eat at times. The resident also said no one had asked whether she wanted to see a dentist. The record showed a physician progress note documented the broken tooth and recommended that the facility arrange for a dentist to see the resident, but there was no documentation that a dental appointment was scheduled at that time. The DON and SSD stated they were not aware of the broken tooth until later, and the DON said no nursing staff were aware of it. The DON also stated the facility did not have a record of communication about the broken tooth after the physician note was written.
Environmental and Sanitation Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During an inspection of the laundry area, it was observed that the exhaust fan in the soiled linen room was broken and covered in dust, indicating it had been non-functional for some time. Additionally, there were multiple structural issues, including a large hole in the ceiling above a dryer, a hole in the wall below clean hanging clothes, and unfinished sheetrock with holes near the door to the clean laundry area. These conditions were not addressed by the maintenance supervisor, who admitted to being unaware of the broken fan and not having time to repair the holes. In the Spartan unit soiled utility room, clean items such as packaged gowns and unopened gloves were improperly stored next to dirty linen and trash containers. A hopper toilet in the room contained dark brown fluid, and there was a hole in the ceiling above it that was leaking fluid. The infection preventionist confirmed that clean items should not be stored in a soiled utility room, and the nursing home administrator acknowledged the need for immediate repair of the ceiling. The maintenance supervisor admitted to not having assessed or repaired the ceiling in the soiled utility room.
Failure to Follow Edema Care Orders and Documentation
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically concerning the management of edema for two residents. For one resident, the facility did not follow physician orders regarding the application and removal of elastic hose stockings, which are used to manage edema. The resident reported that the stockings were not applied as ordered on multiple occasions, and staff interviews confirmed misunderstandings and incorrect documentation regarding the application and removal of the stockings. Observations also revealed inconsistencies between the resident's account and the documented records. Another resident, who had severe cognitive impairment and required maximum assistance, was not properly monitored for edema as per physician orders. The staff failed to document the monitoring of edema changes accurately, using check marks instead of the required symbols to indicate the presence or absence of symptoms. Interviews with staff revealed that the resident often declined to elevate her legs, a recommended intervention, and that the supplemental monitoring documentation was not being completed correctly. The deficiencies highlight a lack of adherence to physician orders and inadequate documentation practices within the facility. The failure to apply and document the use of elastic hose stockings and to monitor edema accurately could potentially impact the residents' health outcomes, although the report does not explicitly state the consequences. The facility's director of nursing acknowledged the issues and indicated plans for staff education to address these deficiencies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Berthoud
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Loveland Village | 4.3 mi | ★★★★★ | 15 | 0 |
| Green House Homes At Mirasol, The | 5.6 mi | ★★★★★ | 0 | 0 |
| Riverbend Health And Rehabilitation Center | 6.3 mi | ★★★★★ | 13 | 0 |
| Life Care Center Of Longmont | 7.5 mi | ★★★★★ | 15 | 0 |
| North Shore Health & Rehab Facility | 7.8 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.