Cycle 1
Health 2024-08-15 · Fire 2024-08-15
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Brush, CO
Eben Ezer Lutheran Care Center
2-star overall rating with 2-star inspections with abuse icon flag with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
122 Hospital Rd, Brush, CO
(970) 842-2861
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
83
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.78
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.06
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.68
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.30
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,066
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9907
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.12
Performance 20.45% · Measure score 2.12 · Achievement 2.12 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.53
Baseline 5.88% · Performance 6.78% · Measure score 3.53 · Achievement 3.53 · Improvement 0
Total nurse turnover
5.05
Baseline 38.89% · Performance 43.02% · Measure score 5.05 · Achievement 5.05 · Improvement 0
Adjusted total nurse staffing
4.29
Baseline 4.18 hours · Performance 4.30 hours · Measure score 4.29 · Achievement 4.29 · Improvement 0.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.55% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 5.06% · Lower 95% interval 6.16% |
| Discharge to community | 46.48% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 43.24% · Lower 95% interval 37.27% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 59.38% |
95.27%
35.9 pts worse
|
Numerator 38 · Denominator 64 |
| Falls with major injury | 7.81% |
0.77%
7 pts worse
|
Numerator 5 · Denominator 64 |
| Discharge self-care score | 35.29% |
53.69%
18.4 pts worse
|
Numerator 18 · Denominator 51 |
| Discharge mobility score | 45.1% |
50.94%
5.8 pts worse
|
Numerator 23 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 64 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.78% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 5.17% · Lower 95% interval 3.89% |
| Staff COVID-19 vaccination coverage | 14.53% |
8.2%
6.3 pts better
|
Numerator 17 · Denominator 117 |
| Staff flu vaccination coverage | 94.51% |
42%
52.5 pts better
|
Numerator 155 · Denominator 164 |
| Discharge function score | 58.82% |
56.45%
2.4 pts better
|
Numerator 30 · Denominator 51 |
| Transfer of health information to provider | 91.3% |
95.95%
4.7 pts worse
|
Numerator 21 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 8 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.9 |
1.7
2.2 pts worse
|
1.8
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 3.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
93.5%
0.4 pts better
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 89.2% · Q2 100.0% · Q3 94.3% · Q4 91.9% · 4Q avg 93.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
94.7%
2.6 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.1% |
3.4%
2.7 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.7% · Q3 7.1% · Q4 8.1% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
7.4%
7 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
5.0%
4.1 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 6.5% · Q3 11.3% · Q4 13.4% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.7% |
11.2%
3.5 pts better
|
19.6%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 10.8% · Q3 4.8% · Q4 8.7% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.4% |
20.6%
4.2 pts better
|
16.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 19.3% · Q3 15.8% · Q4 15.0% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.5% |
15.2%
2.3 pts worse
|
16.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 21.0% · Q3 17.1% · Q4 7.1% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.7% |
14.6%
5.1 pts worse
|
14.9%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 25.0% · Q3 15.0% · Q4 14.1% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.8%
0.2 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.5% |
1.5%
4 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 6.0% · Q3 4.3% · Q4 2.8% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.1% |
22.4%
5.7 pts worse
|
19.8%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 24.5% · Q3 22.6% · Q4 37.8% · 4Q avg 28.1% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
3.7%
1 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 4.1% · Q3 6.1% · Q4 3.2% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 62.0% |
76.4%
14.4 pts worse
|
81.7%
19.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 50.0% · Q2 48.9% · Q3 70.2% · Q4 76.5% · 4Q avg 62.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.1% |
12.8%
4.3 pts worse
|
12.0%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 16.3% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.5%
1.3 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 4.0% · Q4 3.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.2% |
75.6%
5.4 pts worse
|
79.7%
9.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
20.3%
5.3 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 22.4% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-02 · Fire 2023-03-02
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-11-18 · Fire 2021-11-18
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-15
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-14
F · Potential for more than minimal harm
2024-08-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-08-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-14
F · Potential for more than minimal harm
2023-03-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-04
F · Potential for more than minimal harm
2023-03-02
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-01
F · Potential for more than minimal harm
2023-03-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-01
F · Potential for more than minimal harm
2023-03-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-01
F · Potential for more than minimal harm
2023-03-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-09
D · Potential for more than minimal harm
2021-11-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-02-08
D · Potential for more than minimal harm
2021-11-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-16
D · Potential for more than minimal harm
2021-11-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-12-20
D · Potential for more than minimal harm
2021-11-18
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-22
D · Potential for more than minimal harm
2021-11-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-23
D · Potential for more than minimal harm
2021-11-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-20
D · Potential for more than minimal harm
2021-11-18
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2022-02-11
D · Potential for more than minimal harm
2021-11-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-02-12
D · Potential for more than minimal harm
2021-11-18
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-12-21
D · Potential for more than minimal harm
2021-11-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-02-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-30
E · Potential for more than minimal harm
2024-08-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-08-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-07
D · Potential for more than minimal harm
2024-08-15
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-15
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-09-06
G · Actual harm
2023-03-02
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-01-14
G · Actual harm
2023-03-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-30
D · Potential for more than minimal harm
2023-03-02
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-03-30
G · Actual harm
2021-11-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-12-17
G · Actual harm
2021-11-18
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-12-17
D · Potential for more than minimal harm
2021-11-18
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2021-12-17
Penalties and ownership
What sits behind the stars
Ownership
Bass, Sonyou
Corporate Director · Individual
Chapin, Robert
Corporate Director · Individual
Eben Ezer Lutheran Care Center
Operational/Managerial Control · Organization
Frasier, Mark
Corporate Director · Individual
Hergenreter, Shelly
Corporate Officer · Individual
Hergenreter, Shelly
W-2 Managing Employee · Individual
Lee, Michael
Corporate Director · Individual
Lefever, Travis
Corporate Director · Individual
Mason, Leslie
Corporate Officer · Individual
Mason, Leslie
W-2 Managing Employee · Individual
Schaefer, Roger
Corporate Director · Individual
Tekroney, Michael
Corporate Director · Individual
Thistle, Jennifer
Corporate Director · Individual
Vannoy, Douglas
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
South Platte Rehabilitation And Nursing LLC
Brush, CO
1-star overall rating with 2-star inspections with $49,843 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Valley View Villa
Fort Morgan, CO
5-star overall rating with 5-star inspections with $7,443 in total fines with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Sterling Rehabilitation And Nursing, LLC
Sterling, CO
1-star overall rating with 2-star inspections with $117,325 in total fines with 18 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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