Deficiency timeline
Burlington Health and Rehabilitation Center
Dated inspection findings, penalties, and correction notes for this nursing home in Burlington, WI. Newest events first.
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0806: Nutrition and Dietary
Nutrition & dietary
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected Jan 22, 2026
- Class IIIPotential for more than minimal harm (F)Complaint-relatedcms
F0851: Administration
Administration
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (F)Complaint-relatedcms
F0880: Infection Control
Infection control
Provide and implement an infection prevention and control program.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (F)Complaint-relatedcms
F0925: Environmental
Environment
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0600: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (E)cms
F0641: Resident Assessment and Care Planning
Assessment & care planning
Ensure each resident receives an accurate assessment.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0677: Quality of Life and Care
Quality of life & care
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0684: Quality of Life and Care
Quality of life & care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (E)cms
F0761: Pharmacy Service
Pharmacy services
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.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0550: Resident Rights
Resident rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0561: Resident Rights
Resident rights
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (F)Complaint-relatedcms
F0812: Nutrition and Dietary
Nutrition & dietary
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0584: Resident Rights
Resident rights
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.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0609: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0578: Resident Rights
Resident rights
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.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0610: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Respond appropriately to all alleged violations.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0645: Resident Assessment and Care Planning
Assessment & care planning
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0686: Quality of Life and Care
Quality of life & care
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0688: Quality of Life and Care
Quality of life & care
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.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0689: Quality of Life and Care
Quality of life & care
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0695: Quality of Life and Care
Quality of life & care
Provide safe and appropriate respiratory care for a resident when needed.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0697: Quality of Life and Care
Quality of life & care
Provide safe, appropriate pain management for a resident who requires such services.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0700: Quality of Life and Care
Quality of life & care
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.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0803: Nutrition and Dietary
Nutrition & dietary
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.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)cms
F0849: Administration
Administration
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.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (F)cms
F0576: Resident Rights
Resident rights
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected Sep 12, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0880: Infection Control
Infection control
Provide and implement an infection prevention and control program.
Corrected Jul 22, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0755: Pharmacy Service
Pharmacy services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected Jun 5, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0760: Pharmacy Service
Pharmacy services
Ensure that residents are free from significant medication errors.
Corrected Jun 5, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0698: Quality of Life and Care
Quality of life & care
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected Jun 5, 2025
- Class IIIPotential for more than minimal harm (F)Complaint-relatedcms
F0803: Nutrition and Dietary
Nutrition & dietary
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.
Corrected Jun 5, 2025
- Class IIIPotential for more than minimal harm (F)Complaint-relatedcms
F0812: Nutrition and Dietary
Nutrition & dietary
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected Jun 5, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0554: Resident Rights
Resident rights
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected Jun 5, 2025
- Class IIIPotential for more than minimal harm (F)Complaint-relatedcms
F0801: Nutrition and Dietary
Nutrition & dietary
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.
Corrected Jun 5, 2025
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0842: Resident Assessment and Care Planning
Assessment & care planning
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected Feb 27, 2025
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0692: Quality of Life and Care
Quality of life & care
Provide enough food/fluids to maintain a resident's health.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0695: Quality of Life and Care
Quality of life & care
Provide safe and appropriate respiratory care for a resident when needed.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0757: Pharmacy Service
Pharmacy services
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0759: Pharmacy Service
Pharmacy services
Ensure medication error rates are not 5 percent or greater.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0760: Pharmacy Service
Pharmacy services
Ensure that residents are free from significant medication errors.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0880: Infection Control
Infection control
Provide and implement an infection prevention and control program.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0585: Resident Rights
Resident rights
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.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0610: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Respond appropriately to all alleged violations.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0755: Pharmacy Service
Pharmacy services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0580: Resident Rights
Resident rights
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0609: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0661: Resident Assessment and Care Planning
Assessment & care planning
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0684: Quality of Life and Care
Quality of life & care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0689: Quality of Life and Care
Quality of life & care
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Oct 31, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0745: Quality of Life and Care
Quality of life & care
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected Jun 12, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0760: Pharmacy Service
Pharmacy services
Ensure that residents are free from significant medication errors.
Corrected Jun 13, 2024
- Class IIActual harm (G)Complaint-relatedcms
F0686: Quality of Life and Care
Quality of life & care
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Jul 5, 2024
- Class IIIPotential for more than minimal harm (F)cms
F0812: Nutrition and Dietary
Nutrition & dietary
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (E)cms
F0559: Resident Rights
Resident rights
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (E)cms
F0700: Quality of Life and Care
Quality of life & care
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.
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0609: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0644: Resident Assessment and Care Planning
Assessment & care planning
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0655: Resident Assessment and Care Planning
Assessment & care planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0685: Quality of Life and Care
Quality of life & care
Assist a resident in gaining access to vision and hearing services.
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0690: Quality of Life and Care
Quality of life & care
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0693: Quality of Life and Care
Quality of life & care
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.
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0698: Quality of Life and Care
Quality of life & care
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0756: Pharmacy Service
Pharmacy services
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0761: Pharmacy Service
Pharmacy services
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.
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0849: Administration
Administration
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.
Corrected Jun 13, 2024
- Class IIIPotential for more than minimal harm (D)cms
F0880: Infection Control
Infection control
Provide and implement an infection prevention and control program.
Corrected Jun 13, 2024
- Fine $86,790cms
CMS fine
Civil money penalty recorded in CMS Nursing Home Compare.
- cms
Payment denial
Medicare/Medicaid payment denial issued following a survey deficiency.
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0609: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Dec 6, 2023
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0610: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Respond appropriately to all alleged violations.
Corrected Dec 6, 2023
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0623: Resident Rights
Resident rights
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected Dec 6, 2023
- Class IImmediate jeopardy (J)Complaint-relatedcms
F0740: Quality of Life and Care
Quality of life & care
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected Dec 6, 2023
- Class IImmediate jeopardy (J)Complaint-relatedcms
F0841: Nursing and Physician Services
Nursing & physician services
Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.
Corrected Dec 6, 2023
- Class IImmediate jeopardy (J)Complaint-relatedcms
F0689: Quality of Life and Care
Quality of life & care
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Oct 17, 2023
- Class IIActual harm (G)Complaint-relatedcms
F0740: Quality of Life and Care
Quality of life & care
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected Dec 6, 2023
- Class IIIPotential for more than minimal harm (F)Complaint-relatedcms
F0566: Resident Rights
Resident rights
1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.
Corrected Oct 17, 2023
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0610: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Respond appropriately to all alleged violations.
Corrected Dec 6, 2023
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0730: Nursing and Physician Services
Nursing & physician services
Observe each nurse aide's job performance and give regular training.
Corrected Oct 17, 2023
- Class IIIPotential for more than minimal harm (E)Complaint-relatedcms
F0838: Administration
Administration
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.
Corrected Oct 17, 2023
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0580: Resident Rights
Resident rights
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected Oct 17, 2023
- Class IIIPotential for more than minimal harm (D)Complaint-relatedcms
F0609: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Dec 6, 2023
- cms
Payment denial
Medicare/Medicaid payment denial issued following a survey deficiency.
- Fine $285,068cms
CMS fine
Civil money penalty recorded in CMS Nursing Home Compare.
- Class IImmediate jeopardy (K)Complaint-relatedcms
F0678: Quality of Life and Care
Quality of life & care
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected Oct 17, 2023
- Class IImmediate jeopardy (J)Complaint-relatedcms
F0600: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected Oct 17, 2023
- Class IIIPotential for more than minimal harm (E)cms
F0607: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected Apr 18, 2023
- Class IIIPotential for more than minimal harm (E)cms
F0757: Pharmacy Service
Pharmacy services
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected Apr 18, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0600: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected Apr 18, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0609: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected Apr 18, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0610: Freedom from Abuse, Neglect, and Exploitation
Abuse, neglect & exploitation
Respond appropriately to all alleged violations.
Corrected Apr 18, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0684: Quality of Life and Care
Quality of life & care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected Apr 18, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0689: Quality of Life and Care
Quality of life & care
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected Apr 18, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0692: Quality of Life and Care
Quality of life & care
Provide enough food/fluids to maintain a resident's health.
Corrected Apr 18, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0758: Pharmacy Service
Pharmacy services
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.
Corrected Apr 18, 2023
- Class IIIPotential for more than minimal harm (D)cms
F0883: Infection Control
Infection control
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected Apr 18, 2023
- Class IImmediate jeopardy (J)cms
F0686: Quality of Life and Care
Quality of life & care
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected Apr 18, 2023
- Class IIIPotential for more than minimal harm (F)cms
F0812: Nutrition and Dietary
Nutrition & dietary
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected Apr 18, 2023
- Class IIIPotential for more than minimal harm (F)cms
F0838: Administration
Administration
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.
Corrected Apr 18, 2023
- Class IIIPotential for more than minimal harm (F)cms
F0880: Infection Control
Infection control
Provide and implement an infection prevention and control program.
Corrected Apr 18, 2023
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AHCA class rollups without individual citation dates appear as a single summary row. CMS nursing home deficiencies include survey date, tag, category, scope/severity, and fine amounts when published. Back to community profile