Eben Ezer Lutheran Care Center
122 HOSPITAL RD, Brush, CO, 80723
Yes. Federal inspectors cited 7 deficiencies against Eben Ezer Lutheran Care Center in Brush, Colorado at its most recent standard inspection on 2024-08-15, 1 of them arising from complaints. 4 findings have been recorded at the actual-harm level. CMS currently flags this home for abuse. Medicare rates it 2 out of 5 overall.
Every deficiency on record, by how serious CMS judged it
CMS grades each finding from A to L on two axes: how badly residents were affected, and how many. These are its bands, not ours. The figures cover every standard and complaint survey on record, which is a longer window than the rating cycle above.
The last 13 findings, newest first
Each is the federal requirement the home was found not to meet, in CMS’s own wording, with the tag number so it can be looked up against the inspection report.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · F0600 · 2025-12-03 · from a complaint · No actual harm, potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · F0812 · 2024-08-15 · standard survey · No actual harm, potential for more than minimal harm
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · F0880 · 2024-08-15 · standard survey · No actual harm, potential for more than minimal harm
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · F0658 · 2024-08-15 · standard survey · No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2024-08-15 · standard survey · No actual harm, potential for more than minimal harm
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.
Quality of Life and Care Deficiencies · F0700 · 2024-08-15 · standard survey · No actual harm, potential for more than minimal harm
Observe each nurse aide's job performance and give regular training.
Nursing and Physician Services Deficiencies · F0730 · 2024-08-15 · standard survey · No actual harm, potential for more than minimal harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies · F0600 · 2023-03-02 · standard survey · Actual harm to a resident
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2023-03-02 · standard survey · Actual harm to a resident
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.
Pharmacy Service Deficiencies · F0761 · 2023-03-02 · standard survey · No actual harm, potential for more than minimal harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · F0689 · 2021-11-18 · standard survey · Actual harm to a resident
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.
Pharmacy Service Deficiencies · F0758 · 2021-11-18 · standard survey · Actual harm to a resident
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Quality of Life and Care Deficiencies · F0744 · 2021-11-18 · standard survey · No actual harm, potential for more than minimal harm
How CMS scores this home
These stars are Medicare’s, not ours — we publish no rating of our own. They are reproduced here because they are part of the public record.
Who owns Eben Ezer Lutheran Care Center
Nursing homes are frequently owned through layers of companies, and the name over the door is rarely the one that holds the licence. This is the ownership CMS has on file.
| Owner | Role | Share | Since |
|---|---|---|---|
| HERGENRETER, SHELLY | Individual | NOT APPLICABLE | since 09/01/2007 |
| MASON, LESLIE | Individual | NOT APPLICABLE | since 06/03/2011 |
| BASS, SONYOU | Individual | NOT APPLICABLE | since 07/01/2024 |
| CHAPIN, ROBERT | Individual | NOT APPLICABLE | since 07/01/2024 |
| FRASIER, MARK | Individual | NOT APPLICABLE | since 07/01/2024 |
| LEE, MICHAEL | Individual | NOT APPLICABLE | since 07/01/2024 |
| LEFEVER, TRAVIS | Individual | NOT APPLICABLE | since 07/01/2024 |
| SCHAEFER, ROGER | Individual | NOT APPLICABLE | since 07/01/2024 |
| TEKRONEY, MICHAEL | Individual | NOT APPLICABLE | since 07/01/2024 |
| THISTLE, JENNIFER | Individual | NOT APPLICABLE | since 07/01/2024 |
| VANNOY, DOUGLAS | Individual | NOT APPLICABLE | since 07/01/2024 |
| HERGENRETER, SHELLY | Individual | NOT APPLICABLE | since 07/06/2005 |
Ask Eben Ezer Lutheran Care Center a question
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Source: Centers for Medicare & Medicaid Services, Nursing Home Care Compare. Retrieved 2026-07-29. Facility number 065163.
Figures reproduce the state’s own totals and are not re-aggregated. Methodology · Report a correction