Berthoud Care and Rehabilitation

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to protect the residents' rights to privacy regarding mail delivered to the facility for one (#15) out of five residents reviewed out of 42 sample residents. Specifically, the facility failed to maintain residents' confidentiality by delivering mail opened.

Inspectors wroteBased on observations, record review and interviews, the facility failed to prevent misappropriation of property for one (#42) of five residents reviewed out of 42 sample residents. Specifically, the facility failed to prevent the theft of Resident #42's credit card, resulting in unauthorized charges and the theft of approximately $100.00 in cash by a staff member.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#29) of two residents reviewed for ancillary services, such as dental services, out of 42 sample residents received dental services timely. Specifically, the facility failed to arrange dental services for Resident #29 after she had a broken tooth.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to: -Ensure the laundry area was free from multiple environmental and sanitary concerns; and, -Ensure clean and dirty storage were maintained in separate locations.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#2 and #5) of five residents reviewed for edema care out of 30 sample residents. Specifically, the facility failed to: -Ensure physician orders were followed for the application and removal of elastic hose stockings (used to increase circulation, to prevent blood clots and reduce swelling) for Resident #2; and, -Ensure complete documentation of Resident #5's edema was completed accurately per physician order for Resident #5.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that five out of five certified nursing assistants (CNA) were able to demonstrate skills and techniques necessary to care for residents' needs. Specifically, the facility failed to conduct yearly staff competencies for certified nursing assistants.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to provide services for one (#172) out 31 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #172's vital signs were monitored prior to the administration of a blood pressure medication.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for one (#47) of two residents out of 31 sample residents. Specifically, the facility failed to ensure Resident #47's socialization needs were met by developing a person-centered activity plan.

Inspectors wroteBased on interviews and record review, the facility failed to ensure two (#64 and #55) of two out of 31 sample residents received the appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to: -Ensure Resident #64 was provided psychosocial support after he had voiced difficulty in adjusting to his new level of care and admission to the facility; and, -Ensure Resident #55 was provided person-centered interventions to address the resident's behavior and provided continued psychosocial support.

Inspectors wroteBased on record review and staff interviews, the facility failed to act upon recommendations by the pharmacist in a timely manner for two (#41 and #45) of five residents reviewed out of 31 sample residents. Specifically, the facility failed to ensure a response to pharmacist recommendations from monthly medication regimen reviews for: -Resident #41 regarding the physician's recommendation to discuss the risk and benefits of the drug interaction of Tramadol, Trazodone, Bupropion, and Ativan (psychotropic and pain medications); and, -Resident #45 regarding the physician's recommendation to refer medication questions to the hospice provider.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to provide therapeutic and mechanically altered diets consistent with dietary orders for two (#51 and #66) of two out of 31 sample residents. Specifically, the facility failed to: -Ensure Resident #51 was served puree textured vegetables, which was ordered by the physician; and, -Ensure Resident #66 was served large portions, which was ordered by the physician.