Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eben Ezer Lutheran Care Center during CMS and state inspections, most recent first.
Six residents were not protected from physical abuse by other residents, with repeated incidents of hitting, slapping, and aggression occurring among individuals with dementia and severe cognitive impairment. Despite documented behavioral histories and care plans, staff were unable to prevent altercations, and supervision in common areas was insufficient. Facility leadership did not recognize these incidents as abuse due to the cognitive status of those involved, but surveyors determined that abuse did occur.
The facility failed to maintain proper food storage, handling, and reheating standards. Observations revealed unlabeled and spoiled food items, improper hand hygiene by staff handling ready-to-eat foods, and inadequate reheating of food to the required temperature. The dietary manager acknowledged these issues, emphasizing the importance of proper procedures to prevent cross-contamination and foodborne illnesses.
The facility failed to maintain a sanitary environment, with a housekeeper not performing proper hand hygiene and using the same cleaning materials across different areas. Additionally, an LPN did not follow enhanced barrier precautions during wound care, failing to wear a gown, establish a clean field, or sanitize equipment. These deficiencies were confirmed through staff interviews.
A resident with multiple medical conditions did not have clear dosage instructions for several topical medications in their physician's orders. The facility staff, including a CNA and an LPN, recognized the importance of complete prescription information but did not administer the medication until the order was clarified. The DON was unaware of the missing dosage instructions, indicating a lapse in ensuring accurate medication orders.
A resident with a history of falling and skin injuries was not consistently provided with protective interventions, such as arm sleeves, in a timely manner. Despite multiple skin injuries, the facility failed to update the resident's care plan with necessary interventions until during a survey. Staff interviews revealed a lack of communication and documentation regarding the resident's care plan, contributing to ongoing risks.
A facility failed to use a person-centered approach for a resident's bed rail use, leading to a deficiency. The resident, with multiple medical conditions, was unaware of the bed rail's purpose. The facility did not assess or document interventions before using bed rails, and the care plan lacked specificity. Staff interviews revealed gaps in communication and documentation, with the DON acknowledging incomplete evaluations and missing documentation of risks and benefits.
The facility did not complete a performance review and provide regular in-service education for a CNA who scored 50% in key areas during their annual review. The DON was unaware that performance reviews required an in-service plan based on outcomes, despite acknowledging the CNA's low score and the need for improvement.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect six out of seven sampled residents from abuse, including multiple incidents of physical abuse between residents. Several residents with severe cognitive impairment and dementia were involved in repeated altercations, including hitting, slapping, and other forms of physical aggression. Despite the facility's abuse policy stating that all residents should be free from abuse and that staff should monitor for signs and symptoms, staff were unable to prevent or adequately intervene in these incidents. In each case, the facility's investigations concluded that physical abuse was not substantiated due to lack of injury and the cognitive status of the assailants, but the surveyors determined that abuse did occur because the actions were willful, regardless of cognitive impairment. Multiple incidents involved a resident with a history of delusions, agitation, and physical aggression, who struck other residents on several occasions. This resident was known to wander, enter other residents' rooms, and become easily agitated, especially when she believed others were taking her belongings. Staff and care plans documented her behavioral issues and interventions such as redirection and increased supervision, but these measures were not sufficient to prevent repeated episodes of physical aggression. Other residents involved also had significant cognitive impairments and histories of behavioral disturbances, with some altercations occurring when residents entered each other's personal spaces or rooms. Staff interviews confirmed awareness of the behavioral challenges and the frequency of altercations, with staff acknowledging that supervision in common areas was insufficient at times. The facility's leadership expressed a belief that residents with dementia could not be willful in their actions, which influenced their interpretation of abuse incidents. However, the survey findings highlighted that the facility did not ensure adequate supervision, monitoring, or interventions to prevent abuse, resulting in multiple residents not being kept free from physical abuse by other residents.
Deficiencies in Food Storage, Handling, and Reheating
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and service standards, leading to several deficiencies. Observations revealed that food items were not labeled, dated, or discarded in a timely manner. For instance, avocados in the main kitchen refrigerator were found to be dark and mushy, indicating spoilage, and were subsequently discarded by the registered dietitian. Additionally, a large sheet pan with an unlabeled red pureed item and a cookie sheet with uncovered red cake and white frosting were found in the freezer. In the East unit refrigerator, opened cartons of liquid thickener lacked opened dates, and one carton was past its seven-day usage period. The dietary manager acknowledged these issues, stating that the avocados should have been discarded earlier and that the pureed food and cake should have been covered. The facility also failed to ensure that ready-to-eat foods were handled in a sanitary manner. During an observation in the Elim/Deaconess dining unit, a dietary aide was seen using the same pair of gloves for multiple tasks without performing hand hygiene between tasks. The aide handled bread, toast, and a sweet potato with the same gloves, and changed gloves without washing hands. The dietary manager confirmed that staff should wash their hands between tasks and after changing gloves to prevent cross-contamination and foodborne illnesses. Furthermore, the facility did not reheat food to the appropriate temperature. During the same observation period, a dietary aide reheated a single-serve can of tomato soup in the microwave for 30 seconds without checking its temperature to ensure it reached the required 165 degrees Fahrenheit. The dietary manager stated that food should be reheated to this temperature to kill bacteria, highlighting a failure in following proper reheating procedures.
Infection Control Deficiencies in Housekeeping and Wound Care
Penalty
Summary
The facility failed to maintain a sanitary environment, leading to potential transmission of communicable diseases and infections. Observations revealed that a housekeeper did not perform proper hand hygiene before donning gloves and after removing them while cleaning resident rooms. The housekeeper also failed to change gloves and mop heads when transitioning between different areas, such as from the bathroom to the bedroom, which is against the facility's hand hygiene policy. These actions were observed during cleaning activities in two resident rooms, where the housekeeper used the same cleaning materials across different surfaces without proper sanitation. Additionally, the facility did not adhere to proper standards of practice during wound care. An LPN was observed performing a dressing change on a resident's heel wound without wearing a gown, which is required under enhanced barrier precautions (EBP) for residents with wounds. The LPN also failed to establish a clean field on the resident's bedside table and did not sanitize scissors used during the procedure. Furthermore, the LPN did not change gloves or perform hand hygiene before applying a new dressing, and did not protect the cleansed wound by placing a clean disposable cloth under the resident's heel. Interviews with staff, including the DON and the LPN involved, confirmed these lapses in infection control practices. The DON acknowledged the need for proper PPE and hand hygiene during wound care and cleaning activities. The LPN admitted to not wearing the appropriate PPE and failing to follow the facility's wound care policy, which contributed to the deficiencies observed during the survey.
Deficiency in Medication Order Dosage Specification
Penalty
Summary
The facility failed to ensure that the physician's orders for a resident contained the necessary dosage information for medications, which is a critical component of professional standards of quality in medication administration. Specifically, the orders for several topical creams, including Lidocaine 4% cream, Silver Sulfadiazine 1% cream, Icy Hot Lidocaine 4% cream, and Triamcinolone acetonide 0.5% cream, did not specify the amount to be applied. This omission left the nursing staff without clear guidance on how much medication to administer, which is a violation of the 'six rights' of medication administration. The resident involved was over 65 years old and had multiple medical conditions, including type 2 diabetes mellitus with diabetic neuropathy, venous insufficiency, and hypertension. The resident had an open wound on the right lower leg and was dependent on supplemental oxygen. During an interview, the resident reported having pain around the sores on her legs and indicated that the facility provided medication for treatment and pain relief. Observations noted a white bandage and a white substance surrounding the bandages on the resident's lower extremities. Interviews with facility staff, including a CNA with medication aide authority and an LPN, revealed that they were aware of the importance of having complete prescription information, including dosage. Both staff members stated that they would not administer medication without clarifying the order with the provider. However, the creams in the resident's room did not have labels indicating the amount to be used, and the staff did not administer the medication until the order was clarified. The Director of Nursing was also unaware that the prescriptions lacked dosage instructions, which further highlights the oversight in ensuring complete and accurate medication orders.
Failure to Implement and Document Interventions for Skin Injury Prevention
Penalty
Summary
The facility failed to ensure an environment as free of accident hazards as possible for a resident, leading to multiple skin injuries. The resident, who was cognitively intact and had a history of falling, was observed without protective sleeves on his arms, despite being prone to skin injuries. The care plan for the resident was not updated with necessary interventions, such as the use of protective sleeves, until during the survey, despite multiple incidents of skin tears and bruising. The resident experienced several skin injuries, including bruises and skin tears, over a period of time. These incidents were documented in nurse progress notes, but new interventions to prevent further injuries were not consistently implemented or added to the resident's care plan. The facility's staff, including the NHA and DON, acknowledged that interventions such as protective sleeves were offered but not formally documented in the care plan until the survey. Interviews with staff revealed a lack of communication and documentation regarding the resident's care plan and interventions. The NHA and DON admitted that interventions were not consistently added to the care plan, and staff were not adequately informed about the necessary precautions to prevent further skin injuries. This lack of consistent implementation and monitoring of interventions contributed to the ongoing risk of skin injuries for the resident.
Failure to Use Person-Centered Approach for Bed Rail Use
Penalty
Summary
The facility failed to use a person-centered approach in determining the use of bed rails for a resident, leading to a deficiency. The resident, who was over 65 years old and had multiple medical conditions including hemiplegia, hemiparesis, and dementia, was observed with a bed rail attached to the right side of her bed. However, the resident was unaware of the purpose of the bed rail and did not recall using it. The facility did not assess or document the interventions attempted before resorting to bed rails, nor did they ensure the resident's care plan was person-centered. The facility's records revealed several deficiencies in the assessment and documentation process. The comprehensive care plan did not specify the reason for the bed rail's use, and the physician's order lacked details on the placement of the bed rail. The safety device assessment did not clarify why the bed rail was recommended or what alternatives were tried and failed. Additionally, the consent obtained from the resident's representative did not include a discussion of the risks and benefits of using bed rails. Interviews with staff, including a CNA-Med, LPN, and the DON, highlighted gaps in communication and documentation. The DON admitted that the quarterly evaluation of the bed rail's use was not completed, and the risks and benefits were not documented in the resident's electronic medical record. The staff interviews also revealed that the facility's protocol for obtaining informed consent and conducting regular assessments was not followed, contributing to the deficiency.
Failure to Provide In-Service Education Based on Performance Review
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for one of five certified nurse aides (CNA) reviewed. Specifically, CNA #5, who was hired before August 14, 2023, had an annual performance review on October 1, 2023, where they scored 50% in areas such as complaints and grievances, environment, quality improvement, workplace violence, and sexual harassment. Despite this low score, CNA #5 did not have an in-service education plan based on the outcome of the annual performance review. During an interview, the Director of Nursing (DON) stated she was unaware that performance reviews needed to include a regular in-service plan based on the review outcomes. The DON acknowledged that a score of 50% indicated the CNA did not meet expectations and mentioned that CNA #5 worked per diem and had been with the facility for at least a year. The DON also noted that an annual performance review should be completed for all CNAs and that she typically met with CNAs one-on-one to provide education and training if there was an area of improvement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brush
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Platte Rehabilitation And Nursing Llc | 0.5 mi | — | 3 | 1 |
| Valley View Villa | 7.9 mi | — | 1 | 0 |
| Sterling Rehabilitation And Nursing, Llc | 33.5 mi | — | 10 | 0 |
| Devonshire Care Center | 35.4 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.