Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- ColoradoAbove 76% of peers208 rated homes · average 3.1★
- Larimer CountyAbove 67% of peers13 rated homes · average 3.5★
- United StatesAbove 80% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point5★+2.3 vs CO avg
- StaffingCan add or remove a star3★−0.1 vs CO avg
- Quality measuresCan add or remove a star4★−0.2 vs CO avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles5★Top 10%CO avg2.7★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 31% of peersCO avg3.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments4★Above only 22% of peersCO avg4.2★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.29hrsAbove only 36% of peersCO avg3.73Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.67hrsAbove only 39% of peersCO avg0.83Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better45%Above 58% of peersCO avg49%RN turnover57%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above 63% of peersCO avg$25,587Fines · denials0 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthNov 2021 – Jun 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Jun 11, 2024Cycle 1worst E · no actual harm
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Jul 10, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 10, 2024
Feb 16, 2023Cycle 2worst F · no actual harm
- F679Provide activities to meet all resident's needs.Quality of Life and CareD · isolatedCorrected Mar 24, 2023
- F726Ensure 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 ServicesE · patternCorrected Mar 17, 2023
- F742Provide 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 CareD · isolatedCorrected Mar 17, 2023
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Mar 17, 2023
- F808Ensure 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 DietaryD · isolatedCorrected Mar 25, 2023
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Mar 17, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Mar 17, 2023
Nov 9, 2021Cycle 3worst E · no actual harm
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Dec 8, 2021
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsE · patternCorrected Dec 8, 2021
- F603Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Aug 23, 2021
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Dec 8, 2021
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Dec 8, 2021
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Dec 8, 2021
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Dec 8, 2021
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.29hrs
- Registered nursesRN hours only0.67hrs
- Licensed practical nursesLPN hours0.63hrs
- Nurse aidesCNA hours1.99hrs
- Weekend nursingAll staff on Saturdays and Sundays2.84hrs
- Colorado average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better45%Above 58% of peersCO avg 49%
- RN turnoverRegistered nurses only57%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy76 certified beds · ~68 residents a day89%Above 69% of peersCO avg 79%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $0In fines
- 0Fines
- 0Payment denials
- $25,587CO avg in fines
Actions on record
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- The Ensign Group324 facilities in the chain3.2★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Endura Healthcare LLC
- The Ensign Group INC
- Isomed INC
- Malcolm Fraser
- Joseph Graham
- David Jorgensen
- Soon Burnam
- Joseph Graham
- Chad Keetch
- Ami Sato
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 065265 · 855 FRANKLIN AVE, BERTHOUD, CO, 80513.
- Percentiles compare this facility with every rated nursing home in Colorado and Larimer County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
