EBEN EZER LUTHERAN CARE CENTER

BRUSH, CO · 125 beds · Non profit - Corporation

0 Trust Score
Grade: F CRITICAL Risk → Stable

Red Flags

  • This facility has a substantiated finding of abuse
  • 4 citation(s) where residents suffered actual harm

Green Flags

No positive signals identified yet.

Quick Facts

★★☆☆☆
CMS Overall
★★☆☆☆
Health Inspection
7
0.8x state avg
Deficiencies
$26,832
Fines (3-yr)
★★★☆☆
Staffing

Violation Timeline

December 2, 2025

1 deficiency
F0600 Potential Harm Scope/Severity: E

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Show details

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

August 14, 2024

6 deficiencyies
F0658 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

Show details

Ensure services provided by the nursing facility meet professional standards of quality.

F0689 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0700 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

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.

F0730 Potential Harm Scope/Severity: D

Nursing and Physician Services Deficiencies

Show details

Observe each nurse aide's job performance and give regular training.

F0812 Potential Harm Scope/Severity: E

Nutrition and Dietary Deficiencies

Show details

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

F0880 Potential Harm Scope/Severity: E

Infection Control Deficiencies

Show details

Provide and implement an infection prevention and control program.

March 1, 2023

3 deficiencyies
F0689 Actual Harm Scope/Severity: G

Quality of Life and Care Deficiencies

Show details

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0761 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

Show details

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.

F0600 Actual Harm Scope/Severity: G

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Show details

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

November 17, 2021

3 deficiencyies
F0689 Actual Harm Scope/Severity: G

Quality of Life and Care Deficiencies

Show details

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

F0744 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

Show details

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

F0758 Actual Harm Scope/Severity: G

Pharmacy Service Deficiencies

Show details

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.

See full violation history →

Staffing

0.56
RN hrs/res/day
0.80
LPN hrs/res/day
2.95
CNA hrs/res/day
3.90
Weekend hrs/res/day
44%
Total nurse turnover
62%
RN turnover

A nurse checks on each resident roughly every 5.6 hours on average.

Fines & Penalties

  • Fine Mar 1, 2023
    $26,832
Total $26,832

Ownership

Non profit - Corporation Independent (not part of a chain)
  • EBEN EZER LUTHERAN CARE CENTER

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/1966

    Organization
  • BASS, SONYOU

    CORPORATE DIRECTOR

    Since since 07/01/2024

    Individual
  • CHAPIN, ROBERT

    CORPORATE DIRECTOR

    Since since 07/01/2024

    Individual
  • FRASIER, MARK

    CORPORATE DIRECTOR

    Since since 07/01/2024

    Individual
  • LEE, MICHAEL

    CORPORATE DIRECTOR

    Since since 07/01/2024

    Individual
  • LEFEVER, TRAVIS

    CORPORATE DIRECTOR

    Since since 07/01/2024

    Individual
  • SCHAEFER, ROGER

    CORPORATE DIRECTOR

    Since since 07/01/2024

    Individual
  • TEKRONEY, MICHAEL

    CORPORATE DIRECTOR

    Since since 07/01/2024

    Individual
  • THISTLE, JENNIFER

    CORPORATE DIRECTOR

    Since since 07/01/2024

    Individual
  • VANNOY, DOUGLAS

    CORPORATE DIRECTOR

    Since since 07/01/2024

    Individual
  • HERGENRETER, SHELLY

    CORPORATE OFFICER

    Since since 07/06/2005

    Individual
  • MASON, LESLIE

    CORPORATE OFFICER

    Since since 06/03/2011

    Individual
  • HERGENRETER, SHELLY

    W-2 MANAGING EMPLOYEE

    Since since 09/01/2007

    Individual
  • MASON, LESLIE

    W-2 MANAGING EMPLOYEE

    Since since 06/03/2011

    Individual

Nearby Facilities in BRUSH, CO