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

Chain footprint

9 facilities

Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.77

Registered nurse staffing · state 0.83 · national 0.68

LPN hours / resident day

0.42

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

1.51

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

2.70

All reported nurse hours · state 3.70 · national 3.89

Licensed hours

1.19

RN + LPN hours · state 1.51 · national 1.54

Weekend hours

2.10

Weekend nurse staffing · state 3.26 · national 3.43

Weekend RN hours

0.57

Weekend registered nurse coverage · state 0.60 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.74

CMS adjusted RN staffing hours

Adjusted total hours

2.60

CMS adjusted total nurse staffing hours

Case-mix index

1.42

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

54%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,167

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

37.16

Composite VBP score used to determine payment impact.

Payment multiplier

0.9904

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

3.57

Baseline 6.91% · Performance 6.77% · Measure score 3.57 · Achievement 3.57 · Improvement 0.22

Total nurse turnover

6.77

Baseline 62.50% · Performance 36.00% · Measure score 6.77 · Achievement 6.77 · Improvement 6.54

Adjusted total nurse staffing

0.81

Baseline 3.73 hours · Performance 3.31 hours · Measure score 0.81 · Achievement 0.81 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.26%	10.72% 0.5 pts better	No Different than the National Rate · Eligible stays 42 · Observed rate 7.14% · Lower 95% interval 6.84%
Discharge to community	35.13%	50.57% 15.4 pts worse	Worse than the National Rate · Eligible stays 40 · Observed rate 25% · Lower 95% interval 23.43%
Medicare spending per beneficiary	1.34	1.02 0.3 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 25 · Denominator 25
Falls with major injury	4%	0.77% 3.2 pts worse	Numerator 1 · Denominator 25
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 25 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.77%	7.12% 0.4 pts better	No Different than the National Rate · Eligible stays 28 · Observed rate 3.57% · Lower 95% interval 3.26%
Staff COVID-19 vaccination coverage	23.81%	8.2% 15.6 pts better	Numerator 10 · Denominator 42
Staff flu vaccination coverage	78.57%	42% 36.6 pts better	Numerator 33 · Denominator 42
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.

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 · Adjusted 1.6 · Observed 1.4 · Expected 1.7 · Used in QM five-star
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 · Adjusted 4.0 · Observed 4.0 · Expected 1.6 · Used in QM five-star
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 · Q1 96.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0%
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 · 4Q avg 96.6%
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 · Q1 3.8% · Q2 3.7% · Q3 8.0% · Q4 3.8% · 4Q avg 4.8% · Used in QM five-star
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 · Q1 0.0% · Q2 9.1% · Q3 0.0% · Q4 3.8% · 4Q avg 3.3%
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 · Q1 8.3% · Q2 8.0% · Q3 4.2% · Q4 16.0% · 4Q avg 9.2%
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 · Q1 7.7% · Q2 11.1% · Q3 20.0% · Q4 23.1% · 4Q avg 15.4%
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 · Q1 40.0% · Q2 30.0% · Q3 35.0% · Q4 27.3% · 4Q avg 32.9% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
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 · 4Q avg 34.4% · Used in QM five-star
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 · Q1 34.8% · Q2 39.1% · Q3 26.1% · Q4 17.4% · 4Q avg 29.3% · Used in QM five-star
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 · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · Q1 4.2% · Q2 0.0% · Q3 4.2% · Q4 8.0% · 4Q avg 4.1% · Used in QM five-star
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 · Q1 37.1% · Q2 63.6% · Q3 42.8% · Q4 24.9% · 4Q avg 41.4%
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 · Q1 11.9% · Q2 8.6% · Q3 8.6% · Q4 10.2% · 4Q avg 9.8% · Used in QM five-star
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 · 4Q avg 90.2%
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 · Adjusted 15.7% · Observed 15.4% · Expected 11.0% · Used in QM five-star
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 · 4Q avg 3.8% · Used in QM five-star
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 · Adjusted 4.1% · Observed 3.8% · Expected 22.6% · Used in QM five-star

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