Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
EBEN EZER LUTHERAN CARE CENTER
BRUSH, CO · 125 certified beds · Last Life Safety survey August 15, 2024
CMS Certification Number 065163 · first certified July 1981
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CO
20 citations — more than 61% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys on file averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (February 2026 to September 2026), and past the point by which nine in ten CO facilities have been surveyed. This facility’s last Life Safety survey was August 2024. Facilities in CO are typically surveyed 18–25 months after the last one (median 21), measured over 187 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 20 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 20 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 18, 2021 | 10 |
| March 2, 2023 | 5 |
| August 15, 2024 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2023-03-02 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-08-15 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2024-08-15 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2023-03-02 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2024-08-15 |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | 1 | 2024-08-15 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2021-11-18 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2023-03-02 |
What the citations cover
- Smoke Deficiencies 12
- Services Deficiencies 3
- Egress Deficiencies 2
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Services Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 15, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (September 30, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (August 29, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 14, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 11, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (November 14, 2024) |
March 2, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (May 4, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (June 1, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 1, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 1, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 9, 2023) |
November 18, 2021 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (February 8, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 16, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 20, 2021) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (December 22, 2021) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 23, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 20, 2021) |
| K-0522 | Have an externally vented heating system. | Deficient, Provider has date of correction (February 11, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (February 12, 2022) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (December 21, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (February 8, 2022) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.