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GRACE MANOR CARE CENTER Inspection Report, Violations & Safety Grade (BURLINGTON, Colorado)

465 5TH ST, BURLINGTON, Colorado 80807

Phone: 7193467512

CMS Overall:5/5

Overview & Bed Count

Certified Beds

Avg Residents/Day

28.6

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Kit Carson

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

Overall5/5

Health5/5

Staffing3/5

Quality2/5

Metric	This Facility	Colorado Avg	Difference
RN Hours per Resident per Day	0.50	0.81	-0.31
Total Nurse Hours per Resident per Day	3.59	3.69	-0.10
CMS Staffing Rating	3/5	3.1/5	-
Nursing Staff Turnover	31.8%	47%	-

7 health citations on record

Date	Category	Description	Severity
2026-04-21	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2026-04-21	Resident Rights Deficiencies	Allow residents to self-administer drugs if determined clinically appropriate.	D – Moderate Harm Potential
2026-04-21	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2024-04-11	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2024-04-11	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2023-01-11	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2023-01-11	Pharmacy Service Deficiencies	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.	D – Moderate Harm Potential

9 fire safety citations on record

Date	Category	Description	Severity
2026-04-21	Egress Deficiencies	Have properly located and lighted "Exit" signs.	F – Moderate Harm Potential
2026-04-21	Smoke Deficiencies	Install a fire alarm system that can be heard throughout the facility.	F – Moderate Harm Potential
2026-04-21	Services Deficiencies	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	F – Moderate Harm Potential
2026-04-21	Miscellaneous Deficiencies	Have restrictions on the use of portable space heaters.	F – Moderate Harm Potential
2023-01-11	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	F – Moderate Harm Potential
2023-01-11	Egress Deficiencies	Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.	F – Moderate Harm Potential
2023-01-11	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	F – Moderate Harm Potential
2023-01-11	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	F – Moderate Harm Potential
2023-01-11	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	F – Moderate Harm Potential

Total Fine Amount (CMS)

Number of Fines

Total Penalties

No penalty records found.

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Our family advisors can help you find vetted, top-rated facilities in the BURLINGTON area at no cost.

Advisor service is free for families. We may receive referral compensation.