EBEN EZER LUTHERAN CARE CENTER Nursing Home


EBEN EZER LUTHERAN CARE CENTER (CCN: 065163) is a Non profit - Corporation facility located in BRUSH, CO (80723). The facility has an overall rating of 1/5, health inspection rating of 2/5, and a staffing rating of 4/5. It offers 125 certified beds and maintains an average of 73.3 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 4.06235 total hours per resident per day. It has been certified since July 1, 1981 and the last listed health inspection was on March 2, 2023, The facility is located in Morgan county and provides senior and nursing home care.

EBEN EZER LUTHERAN CARE CENTER Summary


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Provider Name: EBEN EZER LUTHERAN CARE CENTER

Address: 122 HOSPITAL RD, BRUSH, CO 80723

Phone: (970) 842-2861

County: Morgan (430)

Ownership Type: Non profit - Corporation

Certified Beds: 125

Average Residents Per Day: 73.3 ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: EBEN EZER LUTHERAN CARE CENTER

First Approved Date: July 1, 1981

Affiliated Entity: ()

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 1 ()

Health Inspection Rating: 2 ()

QM Rating: 1 ()

Long Stay QM Rating: 1 ()

Short Stay QM Rating: 1 ()

Staffing Rating: 4 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.73127, LPN Staff Hours Per Day: 0.7215, RN Staff Hours Per Day: 0.6094, Licensed Staff Hours Per Day: 1.3310

Total Nurse Staff Hours Per Day, per resident: 4.06235

Weekend Nurse Staff Hours: 3.71265, Weekend RN Staff Hours: 0.4564

PT Staff Hours Per Day, per resident: 0.0110

Nurse Staff Turnover: 44.7, Nurse Turnover Note:

RN Turnover: 25.0, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.1742, Case Mix LPN Hours Per Day: 0.6537, Case Mix RN Hours Per Day: 0.2905

Adjusted Nurse Aide Hours Per Day, per resident: 2.55918, Adjusted LPN Hours Per Day: 0.8145, Adjusted RN Hours Per Day: 0.7905

Total Adjusted Nurse Hours Per Day, per resident: 4.10603

Adjusted Weekend Nurse Hours Per Day, per resident: 3.75258

Health Survey Dates and Scores: Cycle 1: 2023-03-02 (Score: 44), Cycle 2: 2021-11-18 (Score: 64), Cycle 3: 2019-07-11 (Score: 32)

Total Weighted Health Score: 48.667

Reported Incidents: 2, Substantiated Complaints: 0

Infection Control Citations:

Fines and Penalties: Number of Fines: 4, Total Fines in Dollars: 63071.26, Payment Denials Number: 0, Total Penalties Number: 4

Location and GPS: 122 HOSPITAL RD,BRUSH,CO,80723 (40.2535, -103.642)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-03-02

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-03-30

Citation on 2023-03-02

Type: Health, Deficiency: 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-03-30

Citation on 2023-03-02

Type: Health, Deficiency: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Past Non-Compliance on 2023-03-02

Citation on 2022-10-06

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Past Non-Compliance on 2022-07-29

Citation on 2021-11-18

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-17

Citation on 2021-11-18

Type: Health, Deficiency: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-17

Citation on 2021-11-18

Type: Health, Deficiency: 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.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-17

Citation on 2019-07-11

Type: Health, Deficiency: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-08-09

Citation on 2019-07-11

Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-08-09

Citation on 2019-07-11

Type: Health, Deficiency: Respond appropriately to all alleged violations.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-08-12

Citation on 2019-07-11

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-08-12

Citation on 2019-07-11

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-08-12


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-03-21

Type: Fire Safety, Tag: 0211, Version: New

Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-04

Citation on 2023-03-21

Type: Fire Safety, Tag: 0291, Version: New

Description: Install emergency lighting that can last at least 1 1/2 hours.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-01

Citation on 2023-03-21

Type: Fire Safety, Tag: 0345, Version: New

Description: Have approved installation, maintenance and testing program for fire alarm systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-01

Citation on 2023-03-21

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-01

Citation on 2023-03-21

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-09

Citation on 2021-12-15

Type: Fire Safety, Tag: 0324, Version: New

Description: Provide properly protected cooking facilities.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-02-08

Citation on 2021-12-15

Type: Fire Safety, Tag: 0345, Version: New

Description: Have approved installation, maintenance and testing program for fire alarm systems.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-16

Citation on 2021-12-15

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-20

Citation on 2021-12-15

Type: Fire Safety, Tag: 0355, Version: New

Description: Properly select, install, inspect, or maintain portable fire extinguishes.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-22

Citation on 2021-12-15

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-23

Citation on 2021-12-15

Type: Fire Safety, Tag: 0511, Version: New

Description: Have properly installed electrical wiring and gas equipment.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-20

Citation on 2021-12-15

Type: Fire Safety, Tag: 0522, Version: New

Description: Have an externally vented heating system.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-02-11

Citation on 2021-12-15

Type: Fire Safety, Tag: 0712, Version: New

Description: Have simulated fire drills held at unexpected times.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-02-12

Citation on 2021-12-15

Type: Fire Safety, Tag: 0911, Version: New

Description: Meet requirements for the installation and maintenance of electrical systems.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-21

Citation on 2021-12-15

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-02-08

Citation on 2019-08-06

Type: Fire Safety, Tag: 0321, Version: New

Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-12

Citation on 2019-08-06

Type: Fire Safety, Tag: 0341, Version: New

Description: Install a fire alarm system that can be heard throughout the facility.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-08-23

Citation on 2019-08-06

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-09-12