Grace Manor Care Center
465 5th St., Burlington, CO 80807 · Kit Carson County · (719) 346-7512
31 certified beds, about 28 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1990
CMS Care Compare ratings, data as of September 1, 2026 · CCN 065284 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on April 21, 2026, inspectors cited 3 health deficiencies (the Colorado average is 8.7, the national average 9.2).
None of its 7 health citations since January 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.78 hours per resident per day, against 3.72 across Colorado and 3.86 nationally. Registered nurses accounted for 0.77 of those hours.
41.7% of nursing staff left within the year CMS measured (Colorado average 47.1%).
CMS links it to Frontline Management, an affiliated group of 9 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 7 health citations on file.
April 21, 2026Standard inspection · 3 citations
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of two units. Specifically, the facility failed to:-Ensure staff followed the correct dwell time when using disinfectant to clean resident rooms and was not sprayed near resident's personal hygiene items; -Ensure housekeeping staff performed hand hygiene appropriately when cleaning resident rooms; and,-Ensure staff changed gloves after moving from dirty to clean task during wound care.
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#8) of three residents out of 25 sample residents. Specifically, the facility failed to ensure:-An assessment was conducted to determine whether the self-administration of medications was clinically appropriate; and,-There was a secured place to store Resident #8's medications.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#16) of five residents reviewed for accidents out of 25 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to ensure person centered fall interventions were consistently implemented for Resident #16, who sustained multiple falls
April 11, 2024Standard inspection · 2 citations
- E 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.
Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly in two of two medication carts and one of one medication rooms. Specifically the facility failed to: -Ensure medications were not loose in medication carts; and, -Ensure expired medications were not stored with current medications in the medication storage room.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observations, record review and interviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#19) of 12 residents out of 15 sample residents. Specifically, the facility failed to have a wound care order in place prior to treatment being provided for Resident #19.
January 11, 2023Standard inspection · 2 citations
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure hand hygiene was performed during medication administration.
- D 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.
Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure two (#20 and #13) of five residents were free from unnecessary psychotropic medications out of 18 sample residents. Specifically, the facility failed to monitor targeted behaviors for psychotropic medications for Resident #20 and #13.
Fire safety inspections
9 fire safety citations on file: 4 on April 21, 2026, 5 on January 11, 2023.
Every fire safety citation9 citations
- F Have properly located and lighted "Exit" signs.
- F Install a fire alarm system that can be heard throughout the facility.
- F Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- F Have restrictions on the use of portable space heaters.
- F Keep aisles, corridors, and exits free of obstruction in case of emergency.
- F Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- F Install emergency lighting that can last at least 1 1/2 hours.
- F Install corridor and hallway doors that block smoke.
- F Have properly installed electrical wiring and gas equipment.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Colorado | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.78 | 3.72 | 3.86 |
| Registered nurses | 0.77 | 0.82 | 0.69 |
| All nursing staff on weekends | 3.20 | 3.29 | 3.42 |
| Nurse aides | 2.53 | ||
| Licensed practical nurses | 0.47 | ||
| Nursing staff turnover (share who left in a year) | 41.7% | 47.1% | 45.8% |
| Registered nurse turnover | not reported | 44.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.85 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.01 on weekdays and 3.20 on weekends, 20% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.56 in April to June 2025 to 3.78 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.78 | 0.77 | 4.01 | 3.20 | 0.0% | 0 of 90 | 28 |
| Oct to Dec 2025 | 3.40 | 0.82 | 3.68 | 2.67 | 0.0% | 0 of 92 | 27 |
| Jul to Sep 2025 | 2.70 | 0.77 | 2.93 | 2.10 | 0.0% | 0 of 92 | 29 |
| Apr to Jun 2025 | 2.56 | 0.78 | 2.79 | 1.99 | 0.0% | 0 of 91 | 29 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Colorado, Jan to Mar 2026 | 3.59 | 0.76 | 3.75 | 3.18 | 5.9% | 0.2% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
Staff pay at this home
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
Official wage estimates for Colorado
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Colorado, all employers | |||
| CNAs (nursing assistants) | $22.78 | $21.42 to $24.00 | 22,240 |
| LPNs and LVNs | $35.52 | $29.76 to $38.37 | 4,920 |
| Registered nurses | $48.20 | $40.67 to $52.37 | 54,490 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Colorado | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 20.4 | 13.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.6 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 5.3 | 1.4 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.9 | 3.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 8.0 | 1.6 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 20.2 | 13.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 7.9 | 3.4 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 25.9 | 20.0 | 15.4 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.2 | 1.4 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 3.2 | 1.7 | 1.8 |
Owners and operators
Legal business name: MADISON SENIOR LIVING MANAGEMENT LLC. CMS links this home to Frontline Management, a group of 9 nursing homes averaging 3.2 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Madison Reality Equities LLC | 5% or greater direct ownership interest | Organization | 100% | 06/12/2012 |
| Langendoen, Gary | 5% or greater indirect ownership interest | Individual | 100% | 07/01/2022 |
| Frontier Management Inc | Operational/managerial control | Organization | 07/01/2013 | |
| Clemmerson, Christina | Operational/managerial control | Individual | 03/16/2015 | |
| Conner, Lori | Operational/managerial control | Individual | 03/28/2014 | |
| Daise, Travis | Operational/managerial control | Individual | 03/01/2022 | |
| Hays, Jasalyn | Operational/managerial control | Individual | 08/01/2008 | |
| Jones-Gregory, Brenda | Operational/managerial control | Individual | 01/13/2020 | |
| Kirkwood, Chelsey | Operational/managerial control | Individual | 10/20/2014 | |
| Ong, Edison | Operational/managerial control | Individual | 04/04/2025 | |
| Salas, Cherise | Operational/managerial control | Individual | 04/04/2025 | |
| Schlichenmayer, Joshua | Operational/managerial control | Individual | 11/12/2014 | |
| Schlichenmayer, Staci | Operational/managerial control | Individual | 12/01/2014 | |
| Scott, Angela | Operational/managerial control | Individual | 04/01/2020 | |
| Vega Ortega, Alejandra | Operational/managerial control | Individual | 01/16/2019 | |
| Weber, Charlotte | Operational/managerial control | Individual | 11/01/1995 | |
| Irwin, Janet | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 04/11/2025 | |
| Leung, Rene | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 04/11/2025 | |
| Veluscek, Steven | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 06/05/2025 | |
| Frontier Management Inc | Adp of the SNF | Organization | 07/11/2025 | |
| Gtm Us Senior Housing Reit, Inc | Adp of the SNF | Organization | 07/11/2025 | |
| Gtm Us Senior Housing Reit, LP | Adp of the SNF | Organization | 01/01/2018 | |
| Key Rehabilitation Inc | Adp of the SNF | Organization | 02/01/2024 | |
| North American Senior Properties, LP | Adp of the SNF | Organization | 07/21/2025 | |
| Remedi Seniorcare of Colorado, LLC | Adp of the SNF | Organization | 05/31/2019 | |
| Wipfli LLP | Adp of the SNF | Organization | 01/01/2024 | |
| Baker, Adam | Adp of the SNF | Individual | 06/05/2025 | |
| Clemmerson, Christina | Adp of the SNF | Individual | 03/16/2025 | |
| Conner, Lori | Adp of the SNF | Individual | 03/28/2014 | |
| Daise, Travis | Adp of the SNF | Individual | 03/01/2022 | |
| Hays, Jasalyn | Adp of the SNF | Individual | 03/01/2022 | |
| Jones-Gregory, Brenda | Adp of the SNF | Individual | 01/13/2020 | |
| Kirkwood, Chelsey | Adp of the SNF | Individual | 10/20/2014 | |
| Ong, Edison | Adp of the SNF | Individual | 04/04/2025 | |
| Salas, Cherise | Adp of the SNF | Individual | 07/01/2013 | |
| Schlichenmayer, Joshua | Adp of the SNF | Individual | 11/12/2014 | |
| Schlichenmayer, Staci | Adp of the SNF | Individual | 12/01/2014 | |
| Scott, Angela | Adp of the SNF | Individual | 04/01/2020 | |
| Vega Ortega, Alejandra | Adp of the SNF | Individual | 01/16/2019 | |
| Weber, Charlotte | Adp of the SNF | Individual | 11/01/1995 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 2 problems in this area, most recently on April 21, 2026: "Provide and implement an infection prevention and control program."
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 2 problems in this area, most recently on April 21, 2026: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 2 problems in this area, most recently on April 11, 2024: "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."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 1 problem in this area, most recently on April 21, 2026: "Allow residents to self-administer drugs if determined clinically appropriate."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.20 hours per resident per day, below the Colorado average of 3.29.
Colorado contacts for a concern about a nursing home
These are the official offices in Colorado. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Colorado Department of Public Health and Environment, Health Facilities and Emergency Medical Services Division, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Colorado State Long-Term Care Ombudsman Program, 303-862-3524. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Find and compare facilities, where Colorado publishes its own records on licensed homes.
Common questions
- What is Grace Manor Care Center's Medicare star rating?
- CMS rates Grace Manor Care Center 5 out of 5 stars overall, with 5 for health inspections, 4 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Grace Manor Care Center get at its last inspection?
- 3 health deficiencies at the standard inspection on April 21, 2026. The Colorado average is 8.7.
- Has Grace Manor Care Center been fined?
- CMS lists no fines in the last three years.
- Does Grace Manor Care Center accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Grace Manor Care Center?
- CMS lists 40 owners and managers, and links the home to Frontline Management. Legal business name: MADISON SENIOR LIVING MANAGEMENT LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.