Burlington Health and Rehabilitation Center
677 E State St · Burlington, WI · 53105 · 2627639531
123 certified beds For profit - Limited Liability company Chain: Champion Care
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results have improved across recent cycles.
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Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
6 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
66% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.48 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.68 | 0.55–0.75 |
| Weekend hours / resident-day | 3.16 | ≈ weekday level |
| Nursing turnover / year | 66% | median 45% |
| Fines (3-yr window) | 2 · $371,858 |
Inspection citations (95 in the current record)
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Potential for harm · D December 22, 2025 · found via complaint
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected January 22, 2026 · Nutrition and Dietary
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Potential for harm · F August 13, 2025
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected September 12, 2025 · Resident Rights
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Potential for harm · D August 13, 2025
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 September 12, 2025 · Resident Rights
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Potential for harm · D August 13, 2025
Respond appropriately to all alleged violations.
Corrected September 12, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E August 13, 2025
Ensure each resident receives an accurate assessment.
Corrected September 12, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 13, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected September 12, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 13, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected September 12, 2025 · Quality of Life and Care
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Potential for harm · D August 13, 2025
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 September 12, 2025 · Quality of Life and Care
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Potential for harm · E August 13, 2025
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 September 12, 2025 · Pharmacy Service
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Potential for harm · D August 13, 2025
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 September 12, 2025 · Administration
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Potential for harm · D August 13, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected September 12, 2025 · Resident Rights
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Potential for harm · D August 13, 2025 · found via complaint
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected September 12, 2025 · Resident Rights
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Potential for harm · D August 13, 2025 · found via complaint
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 September 12, 2025 · Resident Rights
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Potential for harm · E August 13, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 12, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D August 13, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected September 12, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E August 13, 2025 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected September 12, 2025 · Quality of Life and Care
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Potential for harm · E August 13, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 12, 2025 · Quality of Life and Care
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Potential for harm · D August 13, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected September 12, 2025 · Quality of Life and Care
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Potential for harm · D August 13, 2025 · found via complaint
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 September 12, 2025 · Quality of Life and Care
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Potential for harm · D August 13, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 12, 2025 · Quality of Life and Care
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Potential for harm · D August 13, 2025 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected September 12, 2025 · Quality of Life and Care
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Potential for harm · D August 13, 2025 · found via complaint
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 September 12, 2025 · Nutrition and Dietary
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Potential for harm · F August 13, 2025 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected September 12, 2025 · Nutrition and Dietary
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Potential for harm · F August 13, 2025 · found via complaint
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected September 12, 2025 · Administration
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Potential for harm · F August 13, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected September 12, 2025 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| May 14, 2024 | Fine | $86,790 |
| May 14, 2024 | Payment Denial | 22 days |
| September 14, 2023 | Fine | $285,068 |
| September 14, 2023 | Payment Denial | 53 days |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525482 · certified since April 1, 1992. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.