Eben Ezer Lutheran Care Center
122 Hospital Rd, Brush, CO 80723 · Morgan County · 125 certified beds · avg 82 residents/day · certified since Jul 1, 1981
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Mar 2, 2023 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jan 14, 2023 (Past Non-Compliance)
▲ Actual harm, one-off · Mar 2, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 30, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 18, 2021 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 17, 2021 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 18, 2021 · F-0758
The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Why it matters: Unneeded psychiatric medications can leave residents overly sedated and raise the risk of falls and other serious harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Dec 17, 2021 (Deficient, Provider has date of correction)
All citations in the current public record (13)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 3, 2025 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 15, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Aug 15, 2024 | D · Potential for harm, one-off | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Mar 2, 2023 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Mar 2, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 2, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 18, 2021 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 18, 2021 | ▲ G · Actual harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Nov 18, 2021 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 3 | 2 | G ▲ |
| 2023 | 3 | 2 | G ▲ |
| 2024 | 6 | 0 | E |
| 2025 | 1 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.35 | 3.89 | 3.95 | top 24% in Colorado; top 27% in the U.S. |
| Registered Nurse hours | 0.58 | 0.86 | 0.69 | bottom 21% in Colorado; bottom 49% in the U.S. |
| Weekend total nurse staffing | 3.95 | 3.44 | 3.50 | top 20% in Colorado; top 24% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.38 | 0.61 | 0.48 | bottom 20% in Colorado; bottom 48% in the U.S. |
| Total nursing staff turnover (%) | 40.4 | 47.1 | 45.8 | top 31% in Colorado; top 37% in the U.S. |
| RN turnover (%) | 43.8 | 44.6 | 42.9 | top 47% in Colorado; bottom 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.22, RN 0.56, weekend 3.83. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bass, Sonyou | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Bass, Sonyou | Individual | Trustee of the SNF | NOT APPLICABLE | 09/01/2007 |
| Chapin, Robert | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Chapin, Robert | Individual | Trustee of the SNF | NOT APPLICABLE | 01/01/2009 |
| Eben Ezer Lutheran Care Center | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/1966 |
| Frasier, Mark | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Frasier, Mark | Individual | Trustee of the SNF | NOT APPLICABLE | 07/01/2019 |
| Hergenreter, Shelly | Individual | W-2 Managing Employee | NOT APPLICABLE | 09/01/2007 |
| Hergenreter, Shelly | Individual | Corporate Officer | NOT APPLICABLE | 07/06/2005 |
| Lee, Michael | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Lee, Michael | Individual | Trustee of the SNF | NOT APPLICABLE | 07/01/2022 |
| Lefever, Travis | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Lefever, Travis | Individual | Trustee of the SNF | NOT APPLICABLE | 07/01/2024 |
| Mason, Leslie | Individual | W-2 Managing Employee | NOT APPLICABLE | 06/03/2011 |
| Mason, Leslie | Individual | Corporate Officer | NOT APPLICABLE | 06/03/2011 |
| Schaefer, Roger | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Schaefer, Roger | Individual | Trustee of the SNF | NOT APPLICABLE | 07/01/2009 |
| Tekroney, Michael | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
| Tekroney, Michael | Individual | Trustee of the SNF | NOT APPLICABLE | 07/01/2024 |
| Thistle, Jennifer | Individual | Corporate Director | NOT APPLICABLE | 07/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "How often do you evaluate your nurse aides and what ongoing training do they receive?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| South Platte Rehabilitation and Nursing LLC | 0.5 mi | Brush, CO | ★☆☆☆☆ | 2/5 | |
| Valley View Villa | 7.9 mi | Fort Morgan, CO | ★★★★★ | 5/5 |
Compare this facility with the 2 closest →
Facility data as of CMS processing date 2026-08-01. CCN 065163.