The nursing home failed to protect residents from abuse and neglect by others. Cited March 2023 — isolated incident, actual harm.
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F-Tag 600 — 42 CFR §483.12 — S/S: G
Nursing home report
EBEN EZER LUTHERAN CARE CENTER
BRUSH, CO · Medicare-certified · 125 beds
Needs attention
Abuse citationNon-profit
2 of 5 overall
Eben Ezer Lutheran Care Center in Brush, CO has a 2-star overall rating. Its staffing is 4 stars and reported nurse staffing is just below the federal benchmark (4.07 vs. 4.1 hours per resident per day), with 2-star health inspections, no fines in the last 24 months, and a recent abuse citation.
Facility ratings
Health inspections
Staffing
4.0746 hrs/resident/day
Quality measures
Last inspection: December 3, 2025Penalties, last 24 months: $0recent abuse citation
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.0746.
Staffing detail
- Registered nurses
- 0.59
- Licensed practical nurses
- 0.66
- Nurse aides
- 2.82
- Weekend nursing
- 3.73
Hours per resident per day.
Total staff turnover: 42%
Registered nurse turnover: 47%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
18.2%17.5%Improving
Residents with a fall causing major injury
5.7%6.8%Worsening
Residents with pressure ulcers (bedsores)
4.1%1%Improving
Residents with a urinary tract infection
6%1.4%Improving
Residents who lost too much weight
6.5%6.5%No change
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
25%12.3%Improving
Residents whose ability to walk got worse
21%15.7%Improving
Long-stay residents on antianxiety or sleep medication
10.8%7.7%Improving
Short-stay residents newly given an antipsychotic
3.6%0%Improving
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
24.5%17.8%Improving
Residents with depressive symptoms
0%0%No change
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—97.3%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—70.2%—
Short-stay residents given the pneumonia vaccine
48.9%72.7%Improving
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited March 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
The home failed to properly reduce or limit psychotropic medication use and try safer non-drug approaches when appropriate. Cited November 2021 — isolated incident, actual harm.
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F-Tag 758 — 42 CFR §483.45(e) — S/S: G
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited August 2024 — limited pattern, potential for harm.
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F-Tag 812 — 42 CFR §483.60(i) — S/S: E
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited August 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 6 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
Operator & ownership
- Ownership
- Non profit - Corporation
- Occupancy
- 79.4 residents on an average day (64% of 125 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 44 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.