Wisconsin ›Burlington

Burlington Health and Rehabilitation Center

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677 E State St, Burlington, WI 53105 (opens Google Maps) · Racine County · (262) 763-9531· 123 certified beds · avg 91 residents/day · certified since Apr 1, 1992 · Medicare and Medicaid certified

Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →

Part of chain: CHAMPION CARE (22 facilities, chain avg rating 2.2★)

1/5
Health inspection rating (on-site)
inspected Aug 13, 2025
8
Serious findings on record
most recent May 14, 2024
$371,858
Fines, last 3 years
3.77
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

New to these records? How to read an inspection report →

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5 · how star ratings work →

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, isolated · Nov 2, 2023 · F-0740 · triggered by a complaint

The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.

Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Dec 6, 2023 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Nov 2, 2023 · F-0841 · triggered by a complaint

The facility did not designate a physician to serve as medical director — the doctor responsible for overseeing resident care policies and coordinating medical care across the facility.

Why it matters: Without a medical director, there is no doctor accountable for the overall quality of medical care.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Dec 6, 2023 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, pattern · Sep 14, 2023 · F-0678 · triggered by a complaint

The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.

Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.

Severity (K): Immediate jeopardy to resident health or safety was cited. The scope was a pattern: more than a limited occurrence, without being widespread. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Oct 17, 2023 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Sep 14, 2023 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Oct 17, 2023 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Sep 14, 2023 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Oct 17, 2023 (Deficient, Provider has date of correction)

▲ Immediate jeopardy, isolated · Mar 21, 2023 · F-0686

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Apr 18, 2023 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · May 14, 2024 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Jul 5, 2024 (Deficient, Provider has date of correction)

▲ Actual harm, isolated · Sep 14, 2023 · F-0740 · triggered by a complaint

The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.

Why it matters: A resident's untreated mental health needs can worsen and take a toll on their physical health too.

Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.

Corrected: Dec 6, 2023 (Deficient, Provider has date of correction)

Inspection findings in the public record

Showing the latest 3 of 97 inspection findings. Open the full record below to read every finding.

  1. D · Potential for more than minimal harm, isolated

    The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint F-0684

  2. C · Potential for minimal harm, widespread

    The facility has more than 120 beds but did not hire a qualified full-time social worker as required. · from a complaint F-0850

  3. D · Potential for more than minimal harm, isolated

    The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint F-0806

View all 97 inspection findingsShow only the latest 3 findings

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.

DateSeverityWhat the facility was cited for
Jun 18, 2026D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Jun 18, 2026C · Potential for minimal harm, widespreadThe facility has more than 120 beds but did not hire a qualified full-time social worker as required. · from a complaint · F-0850
Dec 22, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint · F-0806
Aug 13, 2025F · Potential for more than minimal harm, widespreadThe facility did not give residents reasonable access to and privacy in using ways to communicate, such as phones, mail, and email. Residents have the right to stay in touch with the outside world privately. · F-0576
Aug 13, 2025F · Potential for more than minimal harm, widespreadThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint · F-0812
Aug 13, 2025F · Potential for more than minimal harm, widespreadThe facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records. · from a complaint · F-0851
Aug 13, 2025F · Potential for more than minimal harm, widespreadThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint · F-0880
Aug 13, 2025F · Potential for more than minimal harm, widespreadThe facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. · from a complaint · F-0925
Aug 13, 2025E · Potential for more than minimal harm, patternThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint · F-0600
Aug 13, 2025E · Potential for more than minimal harm, patternThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641
Aug 13, 2025E · Potential for more than minimal harm, patternThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint · F-0677
Aug 13, 2025E · Potential for more than minimal harm, patternThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Aug 13, 2025E · Potential for more than minimal harm, patternThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint · F-0550
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint · F-0561
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · F-0578
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint · F-0584
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · F-0610
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · F-0645
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · from a complaint · F-0688
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · F-0695
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint · F-0697
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · F-0700
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint · F-0803
Aug 13, 2025D · Potential for more than minimal harm, isolatedThe facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · F-0849
Jun 26, 2025D · Potential for more than minimal harm, isolatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint · F-0880
May 8, 2025F · Potential for more than minimal harm, widespreadThe facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. · from a complaint · F-0801
May 8, 2025F · Potential for more than minimal harm, widespreadThe facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. · from a complaint · F-0803
May 8, 2025F · Potential for more than minimal harm, widespreadThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint · F-0812
May 8, 2025D · Potential for more than minimal harm, isolatedThe facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint · F-0554
May 8, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint · F-0698
May 8, 2025D · Potential for more than minimal harm, isolatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
May 8, 2025D · Potential for more than minimal harm, isolatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760
Jan 30, 2025E · Potential for more than minimal harm, patternThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint · F-0842
Oct 3, 2024E · Potential for more than minimal harm, patternThe facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint · F-0585
Oct 3, 2024E · Potential for more than minimal harm, patternThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610
Oct 3, 2024E · Potential for more than minimal harm, patternThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755
Oct 3, 2024D · Potential for more than minimal harm, isolatedThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint · F-0580
Oct 3, 2024D · Potential for more than minimal harm, isolatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609
Oct 3, 2024D · Potential for more than minimal harm, isolatedWhen a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. · from a complaint · F-0661
Oct 3, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684
Oct 3, 2024D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Oct 3, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint · F-0692
Oct 3, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint · F-0695
Oct 3, 2024D · Potential for more than minimal harm, isolatedThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint · F-0757
Oct 3, 2024D · Potential for more than minimal harm, isolatedThe facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · from a complaint · F-0759
Oct 3, 2024D · Potential for more than minimal harm, isolatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760
Oct 3, 2024D · Potential for more than minimal harm, isolatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint · F-0880
Jun 6, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. · from a complaint · F-0745
May 14, 2024▲ G · Actual harm, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686
May 14, 2024F · Potential for more than minimal harm, widespreadThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
May 14, 2024E · Potential for more than minimal harm, patternThe facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · F-0559
May 14, 2024E · Potential for more than minimal harm, patternThe facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. · F-0700
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · F-0644
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · F-0655
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. · F-0685
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · F-0690
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · F-0693
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · F-0756
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · F-0760
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · F-0849
May 14, 2024D · Potential for more than minimal harm, isolatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880
Nov 2, 2023▲ J · Immediate jeopardy, isolatedThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint · F-0740
Nov 2, 2023▲ J · Immediate jeopardy, isolatedThe facility did not designate a physician to serve as medical director — the doctor responsible for overseeing resident care policies and coordinating medical care across the facility. · from a complaint · F-0841
Nov 2, 2023D · Potential for more than minimal harm, isolatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609
Nov 2, 2023D · Potential for more than minimal harm, isolatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610
Nov 2, 2023D · Potential for more than minimal harm, isolatedThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint · F-0623
Sep 14, 2023▲ K · Immediate jeopardy, patternThe facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint · F-0678
Sep 14, 2023▲ J · Immediate jeopardy, isolatedThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint · F-0600
Sep 14, 2023▲ J · Immediate jeopardy, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689
Sep 14, 2023▲ G · Actual harm, isolatedThe facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint · F-0740
Sep 14, 2023F · Potential for more than minimal harm, widespreadThe facility did not follow the rules about resident work. Residents must never be forced to work for the nursing home, but those who want to work must be allowed to. · from a complaint · F-0566
Sep 14, 2023E · Potential for more than minimal harm, patternThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610
Sep 14, 2023E · Potential for more than minimal harm, patternThe facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint · F-0730
Sep 14, 2023E · Potential for more than minimal harm, patternThe facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint · F-0838
Sep 14, 2023D · Potential for more than minimal harm, isolatedThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint · F-0580
Sep 14, 2023D · Potential for more than minimal harm, isolatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609
Mar 21, 2023▲ J · Immediate jeopardy, isolatedThe facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686
Mar 21, 2023F · Potential for more than minimal harm, widespreadThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812
Mar 21, 2023F · Potential for more than minimal harm, widespreadThe facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · F-0838
Mar 21, 2023F · Potential for more than minimal harm, widespreadThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880
Mar 21, 2023E · Potential for more than minimal harm, patternThe facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · F-0607
Mar 21, 2023E · Potential for more than minimal harm, patternThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · F-0757
Mar 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · F-0600
Mar 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · F-0609
Mar 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · F-0610
Mar 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684
Mar 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689
Mar 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692
Mar 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · F-0758
Mar 21, 2023D · Potential for more than minimal harm, isolatedThe facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · F-0883

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (16 → 25).

Citations by recorded inspection yearPublished citation counts, not a quality score · Source: CMS, 2026-08-01
All citationsSerious citations (G–L)
2023
All citations: 29
Serious citations (G–L): 7
2024
All citations: 31
Serious citations (G–L): 1
2025
All citations: 35
Serious citations (G–L): 0
2026
All citations: 2
Serious citations (G–L): 0

All bars start at zero. Exact values and supporting details remain below.

YearCitationsSerious (G–L)Worst severity that year
2023297K ▲
2024311G ▲
2025350F
202620D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

How to file a complaint about care →

2 fines totaling $371,858, plus 2 Medicare payment denial periods.

Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.

DateTypeAmount / length
May 14, 2024Fine$86,790
May 14, 2024Payment Denial22 days from Jun 13, 2024
Sep 14, 2023Fine$285,068
Sep 14, 2023Payment Denial53 days from Oct 14, 2023

Nurse staffing (from payroll records, adjusted for how much care residents need)

What these staffing numbers mean →

Nurse time, in contextAdjusted hours per resident per day · Source: CMS, 2026-08-01
This facilityWisconsin averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 3.77
Wisconsin average: 4.29
U.S. average: 3.95
Registered Nurse hours
This facility: 0.76
Wisconsin average: 1.01
U.S. average: 0.69
Weekend total nurse staffing
This facility: 3.50
Wisconsin average: 3.84
U.S. average: 3.50

All bars start at zero. Exact values and supporting details remain below.

MeasureThis facilityWisconsin avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.774.293.95bottom 37% in Wisconsin; top 50% in the U.S.
Registered Nurse hours0.761.010.69bottom 28% in Wisconsin; top 31% in the U.S.
Weekend total nurse staffing3.503.843.50bottom 42% in Wisconsin; top 42% in the U.S.
Weekend RN hours (not acuity-adjusted)0.490.680.48bottom 31% in Wisconsin; top 35% in the U.S.
Total nursing staff turnover (%)62.646.945.8bottom 15% in Wisconsin; bottom 13% in the U.S.
RN turnover (%)50.039.742.9bottom 36% in Wisconsin; bottom 39% in the U.S.

Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.58, RN 0.72, weekend 3.32.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.58 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 3/5.

Quality measures: assessments & claims

Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.

Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 2/5

Costs & payment

Price evidence · separate from quality

No verified facility-specific private-pay price is available in our data for Burlington Health and Rehabilitation Center. CMS inspection and staffing records do not tell us what this home will charge you.

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Who owns this facility

How to read ownership records →

Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Ruvel, MenachemIndividual5% or Greater Direct Ownership Interest—02/01/2018
The Bay at Burlington Health and Rehabilitation LLCOrganization5% or Greater Direct Ownership Interest—07/01/2017
Weinberg, YisroelIndividual5% or Greater Direct Ownership Interest—02/01/2018
Ruvel, MenachemIndividualCorporate DirectorNOT APPLICABLE02/01/2018
Ruvel, MenachemIndividualOperational/Managerial ControlNOT APPLICABLE02/01/2018
The Bay at Burlington Health and Rehabilitation LLCOrganizationOperational/Managerial ControlNOT APPLICABLE02/01/2017
Weinberg, YisroelIndividualW-2 Managing EmployeeNOT APPLICABLE02/01/2018
Weinberg, YisroelIndividualCorporate DirectorNOT APPLICABLE02/01/2018

All 8 owning or managing parties CMS has on file are shown — none excluded.

Other facilities in the same chain

CMS lists this facility under the chain Champion Care — 22 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.

Listed by state, then facility name — not a ranking. Showing 8 of the 21 others, continuing from this facility's own place in that list.

Questions to ask on your visit

Full visit checklist →

Print visit checklist

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

  • "What mental health services do you provide on-site, and who delivers them?"
  • "Who is your medical director, and how involved are they in day-to-day care decisions?"
  • "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
  • "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
  • "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
  • "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
  • "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
  • "Do you have a full-time social worker on staff, and how would they work with my family member?"

Also worth asking anywhere

  • "Your weekend nurse staffing is reported below the Wisconsin midpoint — how does the weekend schedule differ from a weekday?"
  • "Can I see the plan of correction for the findings in your most recent state inspection?"
  • "CMS reports 63% total nursing staff turnover here — who on the care team has been with you longest?"
  • "Can I visit again unannounced, at a mealtime or on a weekend?"

Nearby facilities (12 closest of 13 within 20 miles)

FacilityDistanceCityOverallInspectionFlags
Wi Veterans Home-Boland Hall9.5 miUnion Grove, WI★☆☆☆☆1/5abuseSFF
Golden Years of Lake Geneva10.3 miLake Geneva, WI★★★★☆5/5
Geneva Lake Manor10.3 miLake Geneva, WI★☆☆☆☆1/5
Oak Ridge Care Center10.4 miUnion Grove, WI★★★☆☆2/5
East Troy Manor11.3 miEast Troy, WI★★☆☆☆2/5
Lakeland Health Care Ctr14.1 miElkhorn, WI★★★☆☆2/5abuse
Holton Manor14.5 miElkhorn, WI★★☆☆☆2/5
Lindengrove Mukwonago15.0 miMukwonago, WI★★☆☆☆3/5
Williams Bay Health Services16.0 miWilliams Bay, WI★☆☆☆☆1/5
Tudor Oaks Health Center16.3 miMuskego, WI★★☆☆☆2/5
Muskego Health and Rehabilitation Center16.3 miMuskego, WI★★☆☆☆2/5
Complete Care at Grande Prairie18.6 miPleasant Prairie, WI★★☆☆☆2/5

Compare this facility with the 3 closest →

Other facilities in the same county

CMS records place this facility in Racine, WI — 6 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.

Listed by facility name — not a ranking. Homes already in the table above are not repeated here.

All facilities in Burlington →

Facility data as of CMS processing date 2026-08-01. CCN 525482.

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