Burlington Health and Rehabilitation Center
677 E State St, Burlington, WI 53105
Burlington Health and Rehabilitation Center is a nursing home in Burlington, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionAugust 13, 2025 (1 year ago)
- Health citations since March 21, 202387 (Wisconsin average 28)
- Fines in the past three years1, $86,790 in total
- CMS flagsNone listed by CMS
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One email per CMS update, only when something changed: a new citation, a fine, a star rating change, a new owner. Early access follows one home per address.
Email alerts for this home open soon.
CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of June 24, 2026
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility candidate.
Health inspection on June 18, 2026
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 18, 2026.
CMS has cited this home for F0684 4 times since 2023.
Citation F0850. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Hire a qualified full-time social worker in a facility with more than 120 beds.
CMS lists it as corrected on July 18, 2026.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS abuse icon
CMS removed its abuse icon from this home.
Health inspection on December 22, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0806. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
CMS lists it as corrected on January 22, 2026.
CMS update of November 20, 2025
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
Health inspection on August 13, 2025
25 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 25 citations
Citation F0576. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure residents have reasonable access to and privacy in their use of communication methods.
CMS lists it as corrected on September 12, 2025.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for F0812 4 times since 2023.
Citation F0851. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
CMS lists it as corrected on September 12, 2025.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for F0880 5 times since 2023.
Citation F0925. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on September 12, 2025.
Citation F0600. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for F0600 2 times since 2023.
Citation F0641. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on September 12, 2025.
Citation F0677. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on September 12, 2025.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on September 12, 2025.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for F0761 2 times since 2024.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on September 12, 2025.
Citation F0561. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS lists it as corrected on September 12, 2025.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 12, 2025.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 12, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for F0609 5 times since 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for F0610 4 times since 2023.
Citation F0645. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
PASARR screening for Mental disorders or Intellectual Disabilities
CMS lists it as corrected on September 12, 2025.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for F0686 3 times since 2023.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 12, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for F0689 3 times since 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for F0695 2 times since 2024.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on September 12, 2025.
Citation F0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for F0700 2 times since 2024.
Citation F0803. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for F0803 2 times since 2025.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for F0849 2 times since 2024.
Fire safety inspection on August 13, 2025
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation K0271. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on September 12, 2025.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for K0363 3 times since 2023.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on September 12, 2025.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on September 12, 2025.
CMS has cited this home for K0353 2 times since 2024.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Fine
CMS changed the fine from September 14, 2023 from $281,968 to $285,068.
Health inspection on June 26, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 22, 2025.
CMS update of May 28, 2025
Fine
CMS changed the fine from May 14, 2024 from $85,202 to $86,790.
Health inspection on May 8, 2025
7 citationsCMS lists this as a complaint inspection.
Show the 7 citations
Citation F0801. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on June 5, 2025.
Citation F0803. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on June 5, 2025.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 5, 2025.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on June 5, 2025.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on June 5, 2025.
CMS has cited this home for F0698 2 times since 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on June 5, 2025.
CMS has cited this home for F0755 2 times since 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on June 5, 2025.
CMS has cited this home for F0760 3 times since 2024.
CMS update of March 26, 2025
Fine
CMS changed the fine from September 14, 2023 from $276,715 to $281,968.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Fine
CMS changed the fine from May 14, 2024 from $131,080 to $85,202.
Health inspection on January 30, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on February 27, 2025.
CMS update of October 30, 2024
CMS abuse icon
CMS removed its abuse icon from this home.
Fine
CMS changed the fine from September 14, 2023 from $425,715 to $276,715.
Health inspection on October 3, 2024
14 citationsCMS lists this as a complaint inspection.
Show the 14 citations
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on October 31, 2024.
Citation F0610. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on October 31, 2024.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on October 31, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on October 31, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on October 31, 2024.
Citation F0661. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
CMS lists it as corrected on October 31, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on October 31, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 31, 2024.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on October 31, 2024.
CMS has cited this home for F0692 2 times since 2023.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on October 31, 2024.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on October 31, 2024.
CMS has cited this home for F0757 2 times since 2023.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on October 31, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on October 31, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 31, 2024.
CMS update of August 29, 2024
Fine
CMS changed the fine from October 22, 2021 from $193,315 to $179,830.
Fine
CMS changed the fine from December 15, 2022 from $24,478 to $23,200.
Fine
CMS changed the fine from March 21, 2023 from $44,854 to $42,510.
Fine
CMS changed the fine from September 14, 2023 from $276,715 to $425,715.
CMS update of June 26, 2024
Fine
CMS changed the fine from October 22, 2021 from $179,830 to $193,315.
Fine
CMS changed the fine from December 15, 2022 from $23,200 to $24,478.
Fine
CMS changed the fine from March 21, 2023 from $42,510 to $44,854.
June 13, 2024
Payment stoppedCMS stopped payment for new admissions from June 13, 2024, for 22 days.
Health inspection on June 6, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on June 12, 2024.
CMS update of May 29, 2024
Fine
CMS changed the fine from July 28, 2021 from $55,580 to $60,098.
Fine
CMS changed the fine from September 14, 2023 from $425,715 to $276,715.
Health inspection on May 14, 2024
16 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
67 of 323 Wisconsin homes (21%) got a citation at the actual harm level in 2024.
CMS fine of $86,790 on May 14, 2024.
Show the 16 citations
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on July 5, 2024.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on June 13, 2024.
Citation F0559. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
CMS lists it as corrected on June 13, 2024.
Citation F0700. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on June 13, 2024.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on June 13, 2024.
Citation F0644. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
CMS lists it as corrected on June 13, 2024.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on June 13, 2024.
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on June 13, 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on June 13, 2024.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS lists it as corrected on June 13, 2024.
Citation F0698. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate dialysis care/services for a resident who requires such services.
CMS lists it as corrected on June 13, 2024.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on June 13, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on June 13, 2024.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 13, 2024.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 13, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 13, 2024.
Fire safety inspection on May 14, 2024
7 citationsCMS lists this as a standard inspection.
Show the 7 citations
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on June 14, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 6, 2024.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 29, 2024.
CMS has cited this home for K0222 2 times since 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on June 7, 2024.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on June 4, 2024.
Citation K0341. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install a fire alarm system that can be heard throughout the facility.
CMS lists it as corrected on June 11, 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on June 4, 2024.
CMS has cited this home for K0920 2 times since 2023.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
Fire safety inspection on March 27, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation K0914. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
CMS lists it as corrected on April 17, 2024.
CMS update of February 29, 2024
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of December 21, 2023
CMS abuse icon
CMS removed its abuse icon from this home.
Health inspection on November 2, 2023
5 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
22 of 323 Wisconsin homes (7%) got a citation at the immediate jeopardy level in 2023.
Show the 5 citations
Citation F0740. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
CMS lists it as corrected on December 6, 2023.
Citation F0841. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
CMS lists it as corrected on December 6, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on December 6, 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on December 6, 2023.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on December 6, 2023.
Health inspection on March 21, 2023
14 citationsCMS lists this as a standard inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
22 of 323 Wisconsin homes (7%) got a citation at the immediate jeopardy level in 2023.
Show the 14 citations
Citation F0686. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 18, 2023.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 18, 2023.
Citation F0838. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
CMS lists it as corrected on April 18, 2023.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 18, 2023.
Citation F0607. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on April 18, 2023.
Citation F0757. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on April 18, 2023.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on April 18, 2023.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on April 18, 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on April 18, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 18, 2023.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 18, 2023.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 18, 2023.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 18, 2023.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on April 18, 2023.
Fire safety inspection on March 21, 2023
11 citationsCMS lists this as a standard inspection.
Show the 11 citations
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 11, 2023.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on March 4, 2023.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 2, 2023.
Citation K0281. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install proper backup exit lighting.
CMS lists it as corrected on March 4, 2023.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 19, 2023.
Citation K0363. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on March 2, 2023.
Citation K0372. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on March 2, 2023.
Citation K0541. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install properly constructed and protected linen or trash chutes.
CMS lists it as corrected on March 2, 2023.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on April 10, 2023.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on March 2, 2023.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on March 2, 2023.
CMS star ratings
- 2 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 3 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (262) 763-9531
- Last standard health inspection
- August 13, 2025 (1 year ago)
- Certified beds
- 123
- Residents per day, on average
- 93.2
- Ownership type
- For profit - Limited Liability company
- Legal business name
- The Bay at Burlington Health and Rehabilitation LLC
- Chain
- Champion Care
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (87 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- THE BAY AT BURLINGTON HEALTH AND REHABILITATION LLC5% or greater direct ownership interest · no percentage provided · since 07/01/2017
- RUVEL, MENACHEM5% or greater direct ownership interest · no percentage provided · since 02/01/2018
- WEINBERG, YISROEL5% or greater direct ownership interest · no percentage provided · since 02/01/2018
- THE BAY AT BURLINGTON HEALTH AND REHABILITATION LLCOperational/managerial control · not applicable · since 02/01/2017
- RUVEL, MENACHEMOperational/managerial control · not applicable · since 02/01/2018
Questions
When was Burlington Health and Rehabilitation Center last inspected?
CMS lists August 13, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Burlington Health and Rehabilitation Center have?
CMS lists 87 health citations since March 21, 2023. CMS also calls these deficiencies.
Has Burlington Health and Rehabilitation Center been fined?
CMS lists 1 fine in the past three years, $86,790 in total.
What is the CMS star rating of Burlington Health and Rehabilitation Center?
Its CMS overall star rating is 2 of 5.
Is Burlington Health and Rehabilitation Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.