01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-08-15 | 7 | 2024-08-15 | 5 |
| Cycle 2 | 2023-03-02 | 3 | 2023-03-02 | 5 |
| Cycle 3 | 2021-11-18 | 3 | 2021-11-18 | 10 |
CMS CCN 0651632026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Eben Ezer Lutheran Care Center
122 Hospital Rd · Brush, CO 80723 · Morgan County
Certified beds125CMS provider file
Recent citation rows33current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
33 rows in the current release
4 rows carry G–L scope/severity codes; 0 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-03 · HEALTHF0600Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-12-30 · complaint2024-08-15 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2024-09-132024-08-15 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-09-072024-08-15 · HEALTHF0700Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-09-132024-08-15 · HEALTHF0730Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2024-09-062024-08-15 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-09-132024-08-15 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-09-052024-08-15 · FIREK0342Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Correction field: Deficient, Provider has date of correction · 2024-09-302024-08-15 · FIREK0351Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2024-08-292024-08-15 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-10-142024-08-15 · FIREK0355Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Correction field: Deficient, Provider has date of correction · 2024-10-112024-08-15 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2024-11-142023-03-02 · HEALTHF0600Severity G · isolated actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Past Non-Compliance · 2023-01-142023-03-02 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2023-03-302023-03-02 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2023-03-302023-03-02 · FIREK0211Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2023-05-042023-03-02 · FIREK0291Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Correction field: Deficient, Provider has date of correction · 2023-06-012023-03-02 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2023-06-012023-03-02 · FIREK0363Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2023-06-012023-03-02 · FIREK0372Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2023-06-092021-11-18 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2021-12-172021-11-18 · HEALTHF0744Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Correction field: Deficient, Provider has date of correction · 2021-12-172021-11-18 · HEALTHF0758Severity G · isolated actual harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2021-12-172021-11-18 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2022-02-0803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- HERGENRETER, SHELLYIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 09/01/2007
- MASON, LESLIEIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 06/03/2011
- BASS, SONYOUIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- CHAPIN, ROBERTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- FRASIER, MARKIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- LEE, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- LEFEVER, TRAVISIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- SCHAEFER, ROGERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- TEKRONEY, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- THISTLE, JENNIFERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- VANNOY, DOUGLASIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2024
- HERGENRETER, SHELLYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/06/2005
- MASON, LESLIEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/03/2011
- EBEN EZER LUTHERAN CARE CENTEROrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/01/1966
- BASS, SONYOUIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 09/01/2007
- CHAPIN, ROBERTIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 01/01/2009
- FRASIER, MARKIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 07/01/2019
- LEE, MICHAELIndividual · TRUSTEE OF THE SNFNOT APPLICABLE · since 07/01/2022
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.22per resident day
RN hours0.56per resident day
Weekend nurse hours3.83per resident day
Staff turnover40.4%CMS reported field
06 / LOCAL RECORDS
Open the Brush ledger →