Grace Manor Care Center
465 5th St, Burlington, CO 80807 · Kit Carson County · 31 certified beds · avg 28 residents/day · certified since Dec 1, 1990
Part of chain: FRONTLINE MANAGEMENT (9 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★★5/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (7)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 21, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 21, 2026 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Apr 21, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Apr 11, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 11, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 11, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 11, 2023 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 2 | 0 | E |
| 2024 | 2 | 0 | E |
| 2026 | 3 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.76 | 3.89 | 3.95 | top 48% in Colorado; bottom 50% in the U.S. |
| Registered Nurse hours | 0.77 | 0.86 | 0.69 | bottom 48% in Colorado; top 30% in the U.S. |
| Weekend total nurse staffing | 3.18 | 3.44 | 3.50 | bottom 42% in Colorado; bottom 41% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.55 | 0.61 | 0.48 | top 48% in Colorado; top 28% in the U.S. |
| Total nursing staff turnover (%) | 41.7 | 47.1 | 45.8 | top 32% in Colorado; top 41% in the U.S. |
| RN turnover (%) | 0.0 | 44.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.78, RN 0.77, weekend 3.20. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 1/5 · short-stay residents: 2/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Langendoen, Gary | Individual | 5% or Greater Indirect Ownership Interest | 100% | 07/01/2022 |
| Madison Reality Equities LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 06/12/2012 |
| Baker, Adam | Individual | ADP of the SNF | NOT APPLICABLE | 06/05/2025 |
| Clemmerson, Christina | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/16/2015 |
| Clemmerson, Christina | Individual | ADP of the SNF | NOT APPLICABLE | 03/16/2025 |
| Conner, Lori | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/28/2014 |
| Conner, Lori | Individual | ADP of the SNF | NOT APPLICABLE | 03/28/2014 |
| Daise, Travis | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2022 |
| Daise, Travis | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2022 |
| Frontier Management INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/01/2013 |
| Frontier Management INC | Organization | ADP of the SNF | NOT APPLICABLE | 07/11/2025 |
| GTM Us Senior Housing Reit, INC | Organization | ADP of the SNF | NOT APPLICABLE | 07/11/2025 |
| GTM Us Senior Housing Reit, LP | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2018 |
| Hays, Jasalyn | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/01/2008 |
| Hays, Jasalyn | Individual | ADP of the SNF | NOT APPLICABLE | 03/01/2022 |
| Irwin, Janet | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 04/11/2025 |
| Jones-Gregory, Brenda | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/13/2020 |
| Jones-Gregory, Brenda | Individual | ADP of the SNF | NOT APPLICABLE | 01/13/2020 |
| Key Rehabilitation INC | Organization | ADP of the SNF | NOT APPLICABLE | 02/01/2024 |
| Kirkwood, Chelsey | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/20/2014 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your approach to psychiatric medications — how do you try non-drug options first and work to reduce doses over time?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Topside Manor INC | 29.1 mi | Goodland, KS | ★☆☆☆☆ | 1/5 | |
| Cheyenne Manor | 33.6 mi | Cheyenne Wells, CO | ★★★★★ | 5/5 |
Compare this facility with the 2 closest →
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Facility data as of CMS processing date 2026-08-01. CCN 065284.