Eben Ezer Lutheran Care Center
122 Hospital Rd · Brush, CO · 80723 · 9708422861
125 certified beds Non profit - Corporation
Why this verdict
- Carries CMS’s abuse warning icon.
- 4 citations involved actual harm to residents.
- No federal fines or payment denials in CMS’s 3-year window.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 4 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 4.07 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.59 | 0.55–0.75 |
| Weekend hours / resident-day | 3.73 | ≈ weekday level |
| Nursing turnover / year | 42% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (13 in the current record)
-
Potential for harm · E December 3, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 30, 2025 · Freedom from Abuse, Neglect, and Exploitation
-
Potential for harm · D August 15, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected September 13, 2024 · Resident Assessment and Care Planning
-
Potential for harm · D August 15, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 7, 2024 · Quality of Life and Care
-
Potential for harm · D August 15, 2024
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 September 13, 2024 · Quality of Life and Care
-
Potential for harm · D August 15, 2024
Observe each nurse aide's job performance and give regular training.
Corrected September 6, 2024 · Nursing and Physician Services
-
Potential for harm · E August 15, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 13, 2024 · Nutrition and Dietary
-
Potential for harm · E August 15, 2024
Provide and implement an infection prevention and control program.
Corrected September 5, 2024 · Infection Control
-
Actual harm · G March 2, 2023
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 14, 2023 · Freedom from Abuse, Neglect, and Exploitation
-
Actual harm · G March 2, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 30, 2023 · Quality of Life and Care
-
Potential for harm · D March 2, 2023
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 March 30, 2023 · Pharmacy Service
-
Actual harm · G November 18, 2021
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 17, 2021 · Quality of Life and Care
-
Actual harm · G November 18, 2021
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 December 17, 2021 · Pharmacy Service
-
Potential for harm · D November 18, 2021
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected December 17, 2021 · Quality of Life and Care
Better-scoring options nearby
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 065163 · certified since July 1, 1981. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.