Federal inspection record · CMS data as of October 1, 2026
Eben Ezer Lutheran Care Center
122 Hospital Rd, Brush, CO · (970) 842-2861
- Cited for abuse (CMS abuse icon)
- Certified beds
- 125
- Residents per day
- 78
- Ownership
- Non-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- July 1, 1981
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Colorado.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among Colorado homes
Eben Ezer Lutheran Care Center carries 41 inspection points. That is fewer than 70% of Colorado's 208 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Colorado: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–22 pts
- 4★ 22–44 pts
- 3★ 44–70.75 pts
- 2★ 70.75–104 pts
- 1★ over 104 pts
Bars show every rated home in Colorado by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
13 health citations on record since 2021. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (4)
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G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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G
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Everything else, by area of care
Quality of Life and Care3D
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
- D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Freedom from Abuse, Neglect, and Exploitation1E
- E
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Nutrition and Dietary1E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control1E
- E
Provide and implement an infection prevention and control program.
Resident Assessment and Care Planning1D
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Nursing and Physician Services1D
- D
Observe each nurse aide's job performance and give regular training.
Pharmacy Service1D
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspection history
2024-08-15
7 health deficiencies · 5 fire-safety deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2023-03-02
3 health deficiencies · 5 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2021-11-18
3 health deficiencies · 10 fire-safety deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 4 h 17 min of nursing staff time a day, 35 min of it from a registered nurse.
This home
4 h 17 min
Colorado average
3 h 42 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 41% of nursing staff and 31% of registered nurses left in the past year.
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.1 pts better | 1.3 | 1.4 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.5 pts worse | 3.2 | 1.7 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.1 pts better | 94.5% | 93.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine1.4 pts better | 95.1% | 93.7% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury3.8 pts worse | 7.2% | 3.4% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms7.7 pts better | 1.1% | 8.8% | 13.5% |
| Percentage of long-stay residents who lose too much weight4.7 pts worse | 9.5% | 4.8% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication5.5 pts better | 6.1% | 11.6% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication3 pts better | 16.9% | 19.9% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.1 pts better | 0.0% | 0.1% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened3.3 pts better | 8.4% | 11.7% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increasedAbout the same | 12.8% | 12.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.5 pts better | 0.0% | 0.5% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.4 pts worse | 1.8% | 1.4% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence9.7 pts worse | 30.3% | 20.6% | 18.3% |
| Percentage of long-stay residents with pressure ulcersAbout the same | 3.4% | 3.4% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine0.8 pts better | 77.8% | 77.0% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit8.7 pts worse | 20.7% | 12.0% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication0.8 pts better | 0.8% | 1.6% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine1.4 pts better | 75.0% | 73.6% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission8.4 pts better | 12.1% | 20.5% | 23.4% |
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Who owns and runs it
23 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Bass, Sonyou | Corporate Director · Individual | 0% | 1 facilities |
| Bass, Sonyou | Trustee Of The SNF · Individual | 0% | 1 facilities |
| Chapin, Robert | Corporate Director · Individual | 0% | 1 facilities |
| Chapin, Robert | Trustee Of The SNF · Individual | 0% | 1 facilities |
| Eben Ezer Lutheran Care Center | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Frasier, Mark | Corporate Director · Individual | 0% | 1 facilities |
| Frasier, Mark | Trustee Of The SNF · Individual | 0% | 1 facilities |
| Hergenreter, Shelly | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Hergenreter, Shelly | Corporate Officer · Individual | 0% | 1 facilities |
| Lee, Michael | Corporate Director · Individual | 0% | 3 facilities |
| Lee, Michael | Trustee Of The SNF · Individual | 0% | 3 facilities |
| Lefever, Travis | Corporate Director · Individual | 0% | 1 facilities |
| Lefever, Travis | Trustee Of The SNF · Individual | 0% | 1 facilities |
| Mason, Leslie | W-2 Managing Employee · Individual | 0% | 1 facilities |
| Mason, Leslie | Corporate Officer · Individual | 0% | 1 facilities |
| Schaefer, Roger | Corporate Director · Individual | 0% | 1 facilities |
| Schaefer, Roger | Trustee Of The SNF · Individual | 0% | 1 facilities |
| Tekroney, Michael | Corporate Director · Individual | 0% | 1 facilities |
| Tekroney, Michael | Trustee Of The SNF · Individual | 0% | 1 facilities |
| Thistle, Jennifer | Corporate Director · Individual | 0% | 1 facilities |
| Thistle, Jennifer | Trustee Of The SNF · Individual | 0% | 1 facilities |
| Vannoy, Douglas | Corporate Director · Individual | 0% | 1 facilities |
| Vannoy, Douglas | Trustee Of The SNF · Individual | 0% | 1 facilities |
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Fire safety
20 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke12F
- F
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- F
Install an approved automatic sprinkler system.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Install corridor and hallway doors that block smoke.
- F
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Provide properly protected cooking facilities.
- D
Have approved installation, maintenance and testing program for fire alarm systems.
- D
Inspect, test, and maintain automatic sprinkler systems.
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Services3F
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- D
Have properly installed electrical wiring and gas equipment.
- D
Have an externally vented heating system.
Egress2F
- F
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- F
Install emergency lighting that can last at least 1 1/2 hours.
Gas, Vacuum, and Electrical Systems2D
- D
Meet requirements for the installation and maintenance of electrical systems.
- D
Have generator or other power source capable of supplying service within 10 seconds.
Miscellaneous1D
- D
Have simulated fire drills held at unexpected times.
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Other homes nearby
-
South Platte Rehabilitation And Nursing LLC
Brush, CO · The Charly Bello Family, The Maze Family, The Swain Family, & Walter Myers
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 12 min
- Fines
- $36,629
-
Valley View Villa
Fort Morgan, CO · Life Care Centers Of America
★★★★★- Worst citation, 3 yrs
- D
- Nursing / resident / day
- 3 h 53 min
- Fines
- $0
-
Sterling Rehabilitation And Nursing, LLC
Sterling, CO · The Charly Bello Family, The Maze Family, The Swain Family, & Walter Myers
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 27 min
- Fines
- $87,215