Berthoud Care And Rehabilitation
Berthoud, Larimer County, Colorado · CCN 065265 · For-profit (LLC) · part of The Ensign Group (342 facilities, chain average 3.2 stars)
CMS rates Berthoud Care And Rehabilitation 4 of 5 overall as of August 2026. 76 certified beds, 67 residents a day on average. 16 citations on record from the current inspection cycles; no fines on record.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★★★☆ 4 of 5 |
|---|---|
| Health inspections | ★★★★☆ 4 of 5 |
| Staffing | ★★☆☆☆ 2 of 5 |
| Quality measures | ★★★☆☆ 3 of 5 |
| Quality: long-stay / short-stay | 3 / 3 of 5 |
Staffing
| Total nurse staffing | 3.32809 hours per resident per day |
|---|---|
| Registered nurses | 0.67938 hours per resident per day |
| Weekend total | 2.84872 hours per resident per day |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-06-02 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies · tag F0851 |
F No actual harm, with potential for more than minimal harm; widespread | Past Non-Compliance 2026-05-13 |
| 2026-06-02 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-06-29 |
| 2026-06-02 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-06-29 |
| 2026-06-02 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2026-06-29 |
| 2026-06-02 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-29 |
| 2026-06-02 complaint survey |
Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0602 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance 2026-05-20 |
| 2026-06-02 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · tag F0791 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-06-29 |
| 2024-06-11 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · tag F0921 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-07-10 |
| 2024-06-11 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-07-10 |
| 2023-02-16 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2023-03-17 |
| 2023-02-16 | 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. Nursing and Physician Services Deficiencies · tag F0726 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-03-17 |
| 2023-02-16 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-17 |
| 2023-02-16 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-24 |
| 2023-02-16 | 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. Quality of Life and Care Deficiencies · tag F0742 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-17 |
| 2023-02-16 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · tag F0756 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-17 |
| 2023-02-16 | 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. Nutrition and Dietary Deficiencies · tag F0808 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-25 |
Fines and payment denials
No fines or payment denials on record since 2023.
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Ensign Services Inc. Organization | adp of the snf | — | 2020-12-15 |
| Smv Berthoud LLC Organization | adp of the snf | — | 2021-04-01 |
| Isomed Inc. Organization | operational/managerial control | — | 2021-04-01 |
| Fraser, Malcolm Individual | adp of the snf | — | 2025-06-19 |
| Graham, Joseph Individual | adp of the snf | — | 2025-06-19 |
| Jorgensen, David Individual | corporate director | — | 2020-12-15 |
| Burnam, Soon Individual | corporate officer | — | 2020-12-15 |
| Graham, Joseph Individual | corporate officer | — | 2024-02-01 |
| Keetch, Chad Individual | corporate officer | — | 2011-03-01 |
| Sato, Ami Individual | corporate officer | — | 2024-09-20 |
| Port, Barry Individual | individual is an owner, partner or trustee of any adp of the snf | — | 2025-07-08 |
| Fraser, Malcolm Individual | managing control - governing body | — | 2021-04-01 |
| Graham, Joseph Individual | managing control - governing body | — | 2021-04-01 |
| Fraser, Malcolm Individual | operational/managerial control | — | 2021-04-01 |
| Graham, Joseph Individual | operational/managerial control | — | 2021-04-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Berthoud Care And Rehabilitation.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Larimer County.