Burlington Health and Rehabilitation Center

677 E State St, Burlington, WI 53105 · (262) 763-9531
For profit - Limited Liability company · 123 certified beds

Burlington Health and Rehabilitation Center has a 1-star overall rating from Medicare, out of 5. Its last standard inspection, in August 2025, found 25 citations (the Wisconsin average is 9.5). It was fined 1 time in the last three years, $86,790 in all.

Medicare ratings

How to read a nursing home's star ratings

Most recent health inspection

The standard health inspection on August 13, 2025 found 25 citations. What an inspection citation means

• Ensure residents have reasonable access to and privacy in their use of communication methods.August 13, 2025 · F0576 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.August 13, 2025 · F0812 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.August 13, 2025 · F0851 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Provide and implement an infection prevention and control program.August 13, 2025 · F0880 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.August 13, 2025 · F0925 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.August 13, 2025 · F0600 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Ensure each resident receives an accurate assessment.August 13, 2025 · F0641 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Provide care and assistance to perform activities of daily living for any resident who is unable.August 13, 2025 · F0677 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Provide appropriate treatment and care according to orders, resident’s preferences and goals.August 13, 2025 · F0684 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• 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.August 13, 2025 · F0761 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.August 13, 2025 · F0550 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.August 13, 2025 · F0561 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.August 13, 2025 · F0578 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.August 13, 2025 · F0584 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.August 13, 2025 · F0609 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Respond appropriately to all alleged violations.August 13, 2025 · F0610 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• PASARR screening for Mental disorders or Intellectual DisabilitiesAugust 13, 2025 · F0645 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide appropriate pressure ulcer care and prevent new ulcers from developing.August 13, 2025 · F0686 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.August 13, 2025 · F0688 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.August 13, 2025 · F0689 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide safe and appropriate respiratory care for a resident when needed.August 13, 2025 · F0695 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide safe, appropriate pain management for a resident who requires such services.August 13, 2025 · F0697 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.August 13, 2025 · F0700 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.August 13, 2025 · F0803 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.August 13, 2025 · F0849 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few

Complaint inspections, last three years

Inspections after complaints found 50 citations.

• Provide appropriate treatment and care according to orders, resident’s preferences and goals.June 18, 2026 · F0684 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Hire a qualified full-time social worker in a facility with more than 120 beds.June 18, 2026 · F0850 · Level of harm: Potential for minimal harm · Residents affected: Many
• Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.December 22, 2025 · F0806 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.August 13, 2025 · F0550 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.August 13, 2025 · F0561 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.August 13, 2025 · F0584 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.August 13, 2025 · F0600 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.August 13, 2025 · F0609 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide care and assistance to perform activities of daily living for any resident who is unable.August 13, 2025 · F0677 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Provide appropriate treatment and care according to orders, resident’s preferences and goals.August 13, 2025 · F0684 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Provide appropriate pressure ulcer care and prevent new ulcers from developing.August 13, 2025 · F0686 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.August 13, 2025 · F0688 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.August 13, 2025 · F0689 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide safe, appropriate pain management for a resident who requires such services.August 13, 2025 · F0697 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.August 13, 2025 · F0803 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.August 13, 2025 · F0812 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.August 13, 2025 · F0851 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Provide and implement an infection prevention and control program.August 13, 2025 · F0880 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.August 13, 2025 · F0925 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Provide and implement an infection prevention and control program.June 26, 2025 · F0880 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Allow residents to self-administer drugs if determined clinically appropriate.May 8, 2025 · F0554 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide safe, appropriate dialysis care/services for a resident who requires such services.May 8, 2025 · F0698 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.May 8, 2025 · F0755 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure that residents are free from significant medication errors.May 8, 2025 · F0760 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.May 8, 2025 · F0801 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.May 8, 2025 · F0803 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.May 8, 2025 · F0812 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Many
• Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.January 30, 2025 · F0842 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.October 3, 2024 · F0580 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.October 3, 2024 · F0585 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.October 3, 2024 · F0609 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Respond appropriately to all alleged violations.October 3, 2024 · F0610 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.October 3, 2024 · F0661 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide appropriate treatment and care according to orders, resident’s preferences and goals.October 3, 2024 · F0684 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.October 3, 2024 · F0689 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide enough food/fluids to maintain a resident's health.October 3, 2024 · F0692 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide safe and appropriate respiratory care for a resident when needed.October 3, 2024 · F0695 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.October 3, 2024 · F0755 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Some
• Ensure each resident’s drug regimen must be free from unnecessary drugs.October 3, 2024 · F0757 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure medication error rates are not 5 percent or greater.October 3, 2024 · F0759 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure that residents are free from significant medication errors.October 3, 2024 · F0760 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide and implement an infection prevention and control program.October 3, 2024 · F0880 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide medically-related social services to help each resident achieve the highest possible quality of life.June 6, 2024 · F0745 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.May 14, 2024 · F0609 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide appropriate pressure ulcer care and prevent new ulcers from developing.May 14, 2024 · F0686 · Level of harm: Actual harm · Residents affected: Few
• Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.November 2, 2023 · F0609 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Respond appropriately to all alleged violations.November 2, 2023 · F0610 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.November 2, 2023 · F0623 · Level of harm: Minimal harm or potential for actual harm · Residents affected: Few
• Ensure each resident must receive and the facility must provide necessary behavioral health care and services.November 2, 2023 · F0740 · Level of harm: Immediate jeopardy to resident health or safety · Residents affected: Few
• Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.November 2, 2023 · F0841 · Level of harm: Immediate jeopardy to resident health or safety · Residents affected: Few

Fines and payment denials

• Fine of $86,790May 14, 2024
• Medicare payment denial for 22 daysStarting June 13, 2024

Nurse staffing

Hours of nursing care per resident per day, as the home reports them to Medicare through payroll records.

About this home