Berthoud Care and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Berthoud Care and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Jun 2, 2026

  Based on record review and staff interviews, the facility failed to electronically submit complete and accurate direct care staffing information.Specifically, the facility failed to submit to the Center for Medicare and Medicaid Services (CMS) the Payroll Based Journal (PBJ) for the quarter (10/1/25 to 12/31/25) due to an unrecognized coding error.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 5/27/26 to 6/2/26, resulting in the deficiency being cited as past noncompliance with a correction date of 5/13/26.I. Record reviewThe CMS submission report, fiscal year quarter one, 2026 (10/1/25 to 12/31/25), revealed the facility failed to submit the required data for the quarter. […]

• No harm, potential for more than minimal, widespreadF880Feb 16, 2023

  Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in three out of three units. Specifically, the facility failed to: -Ensure orientation for outside agency personnel regarding COVID-19 isolation precautions and donning/doffing of appropriate personal protective equipment; -Ensure an effective water management plan was in place; and, -Ensure residents' rooms were cleaned in a sanitary manner. Findings include: I. COVID-19 isolation precautions A. […]

• No harm, potential for more than minimal, patternF679Jun 2, 2026

  Based on observation, interview, and record review, the facility failed to ensure an ongoing program of meaningful, structured activities was provided to meet the interests and physical, mental, and psychosocial well-being of three out of three units on weekends.Specifically, the facility failed to ensure activities were consistently provided on the weekends to meet the recreational needs of the residents.Findings include:I. Facility policy and procedureThe Activities policy, revised December 2024, was provided by the nursing home administrator (NHA) on 6/2/26 at 12:07 p.m. […]

• No harm, potential for more than minimal, patternF695Jun 2, 2026

  Based on observations, record review, and interviews, the facility failed to ensure respiratory care was provided in accordance with professional standards for three residents (#62, #54, and #29) of six out of 42 sample residents.Specifically, the facility failed to ensure oxygen was administered according to physician's orders for Resident #62, Resident #54 and Resident #29. Findings include: I. Facility policy and procedure The Oxygen Administration, Storage, and Handling policy, dated July 2017, was received from the nursing home administrator (NHA) on 6/2/26 at 12:07 p.m. […]

• No harm, potential for more than minimal, patternF880Jun 2, 2026

  Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one of three units, two out of two shower rooms and two of two soiled utility rooms.Specifically, the facility failed to:-Ensure housekeepers performed appropriate hand hygiene when cleaning residents' rooms;-Ensure drains were covered in two of two shower rooms;-Ensure that the biohazard trash was picked up; and,-Ensure the hopper (basin used for rinsing soiled clothes, emptying and rinsing bedpans) was clean.Findings include:I. Failed to ensure housekeepers performed hand hygieneA. […]