Burlington, CO

Grace Manor Care Center

4-star overall rating with 5-star inspections with $1,609 in total fines with 2 recent health deficiencies

465 5th St, Burlington, CO

(719) 346-7512

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

5 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

31

Certified beds

Average residents

29

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Frontline Management

Operator or chain grouping

Approved since

1990-12-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.77

Registered nurse staffing

LPN hours / resident day

0.42

Licensed practical nurse staffing

Aide hours / resident day

1.51

Nurse aide staffing

Weekend hours

2.10

Weekend nurse staffing

RN turnover

0%

Annual RN turnover

Total nurse turnover

54%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.6	1.3 0.3 pts worse	1.9 0.3 pts better	Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days	4.0	1.7 2.3 pts worse	1.8 2.2 pts worse	Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.0%	93.5% 5.5 pts better	93.4% 5.6 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	96.6%	94.7% 1.9 pts better	95.5% 1.1 pts better	Long Stay · 2024Q3-2025Q2
Percentage of long-stay residents experiencing one or more falls with major injury	4.8%	3.4% 1.4 pts worse	3.3% 1.5 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms	3.3%	7.4% 4.1 pts better	11.4% 8.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight	9.2%	5.0% 4.2 pts worse	5.4% 3.8 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication	15.4%	11.2% 4.2 pts worse	19.6% 4.2 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication	32.9%	20.6% 12.3 pts worse	16.7% 16.2 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose ability to walk independently worsened	34.4%	15.2% 19.2 pts worse	16.3% 18.1 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased	29.3%	14.6% 14.7 pts worse	14.9% 14.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.8% 0.8 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection	4.1%	1.5% 2.6 pts worse	1.7% 2.4 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	41.4%	22.4% 19 pts worse	19.8% 21.6 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers	9.8%	3.7% 6.1 pts worse	5.1% 4.7 pts worse	Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	90.2%	76.4% 13.8 pts better	81.7% 8.5 pts better	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit	15.7%	12.8% 2.9 pts worse	12.0% 3.7 pts worse	Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication	3.8%	1.5% 2.3 pts worse	1.6% 2.2 pts worse	Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were rehospitalized after a nursing home admission	4.1%	20.3% 16.2 pts better	23.9% 19.8 pts better	Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-04-11 · Fire 2024-04-11

2 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2023-01-11 · Fire 2023-01-11

2 health deficiencies

Top issue: Infection Control (1 deficiency)

5 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Cycle 3 Health 2021-09-16 · Fire 2021-09-16

6 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

4 fire-safety deficiencies

Top issue: Services (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2023-01-11

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2023-02-23

F · Potential for more than minimal harm 2023-01-11

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2023-02-23

F · Potential for more than minimal harm 2023-01-11

K291 · Egress Deficiencies

Fire Safety

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

Corrected 2023-02-23

F · Potential for more than minimal harm 2023-01-11

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-02-23

F · Potential for more than minimal harm 2023-01-11

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-02-23

D · Potential for more than minimal harm 2021-09-16

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2021-10-27

D · Potential for more than minimal harm 2021-09-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-10-22

D · Potential for more than minimal harm 2021-09-16

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2021-10-22

D · Potential for more than minimal harm 2021-09-16

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2021-10-22

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-04-11

F761 · Pharmacy Service Deficiencies

Health

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 2024-04-26

D · Potential for more than minimal harm 2024-04-11

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-04-26

G · Actual harm 2023-04-19

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-04-20

E · Potential for more than minimal harm 2023-01-11

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-02-10

D · Potential for more than minimal harm 2023-01-11

F758 · Pharmacy Service Deficiencies

Health

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 2023-02-16

G · Actual harm 2021-09-16

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2021-10-19

E · Potential for more than minimal harm 2021-09-16

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2021-10-19

E · Potential for more than minimal harm 2021-09-16

F813 · Nutrition and Dietary Deficiencies

Health

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Corrected 2021-10-19

E · Potential for more than minimal harm 2021-09-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-10-19

D · Potential for more than minimal harm 2021-09-16

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2021-10-19

Penalties and ownership

What sits behind the stars

$1,609 2023-04-19

Fine

Fine · fine $1,609

Fine

Ownership

Langendoen, Gary

5% Or Greater Indirect Ownership Interest · Individual

100% 1 facilities 2022-07-01

Madison Reality Equities LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2012-06-12

Clemmerson, Christina