Skilled Nursing

Burlington Health and Rehabilitation Center

677 E STATE ST, BURLINGTON, WI 53105

123beds
Skilled Nursingcare types
1/5CMS rating
Updated2026

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Inspection & Compliance

Data from CMS (Centers for Medicare & Medicaid Services), updated weekly. Medicare.gov Care Compare

3.2h

Hrs/resident · weekday

Expected: 3.6h

3.2h

Hrs/resident · weekend

vs 3.2h on weekdays

Not reported

30-day hospital readmission rate

Annual Staff Turnover Rates

High turnover is one of the strongest predictors of care quality. National average CNA turnover is ~75%.

RNs
53%
LPNs
CNAs
66%

Administrator turnover: 2 in the past year — above average

Health Inspection Deficiencies · Last 3 Years

SeriousImmediate Jeopardy0841Severity JNov 2, 2023

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

SeriousImmediate Jeopardy0740Severity JNov 2, 2023

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected: Dec 6, 2023

SeriousImmediate Jeopardy0689Severity JSep 14, 2023

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Oct 17, 2023

SeriousImmediate Jeopardy0678Severity KSep 14, 2023

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

SeriousImmediate Jeopardy0600Severity JSep 14, 2023

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Oct 17, 2023

76 standard deficiencies in the last 3 years

View all
0806Severity DDec 22, 2025

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

0925Severity FAug 13, 2025

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

0880Severity FAug 13, 2025

Provide and implement an infection prevention and control program.

0851Severity FAug 13, 2025

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

0849Severity DAug 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.

0812Severity FAug 13, 2025

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0803Severity DAug 13, 2025

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.

0761Severity EAug 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.

0700Severity DAug 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.

0697Severity DAug 13, 2025

Provide safe, appropriate pain management for a resident who requires such services.

0695Severity DAug 13, 2025

Provide safe and appropriate respiratory care for a resident when needed.

0689Severity DAug 13, 2025

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0688Severity DAug 13, 2025

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.

0686Severity DAug 13, 2025

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0684Severity EAug 13, 2025

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0677Severity EAug 13, 2025

Provide care and assistance to perform activities of daily living for any resident who is unable.

0645Severity DAug 13, 2025

PASARR screening for Mental disorders or Intellectual Disabilities

0641Severity EAug 13, 2025

Ensure each resident receives an accurate assessment.

0610Severity DAug 13, 2025

Respond appropriately to all alleged violations.

0609Severity DAug 13, 2025

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0600Severity EAug 13, 2025

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0584Severity DAug 13, 2025

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.

0578Severity DAug 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.

0576Severity FAug 13, 2025

Ensure residents have reasonable access to and privacy in their use of communication methods.

0561Severity DAug 13, 2025

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

0550Severity DAug 13, 2025

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0880Severity DJun 26, 2025

Provide and implement an infection prevention and control program.

0812Severity FMay 8, 2025

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0803Severity FMay 8, 2025

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.

0801Severity FMay 8, 2025

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.

0760Severity DMay 8, 2025

Ensure that residents are free from significant medication errors.

0755Severity DMay 8, 2025

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0698Severity DMay 8, 2025

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0554Severity DMay 8, 2025

Allow residents to self-administer drugs if determined clinically appropriate.

0842Severity EJan 30, 2025

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0880Severity DOct 3, 2024

Provide and implement an infection prevention and control program.

0760Severity DOct 3, 2024

Ensure that residents are free from significant medication errors.

0759Severity DOct 3, 2024

Ensure medication error rates are not 5 percent or greater.

0757Severity DOct 3, 2024

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0755Severity EOct 3, 2024

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0695Severity DOct 3, 2024

Provide safe and appropriate respiratory care for a resident when needed.

0692Severity DOct 3, 2024

Provide enough food/fluids to maintain a resident's health.

0689Severity DOct 3, 2024

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0684Severity DOct 3, 2024

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0661Severity DOct 3, 2024

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

0610Severity EOct 3, 2024

Respond appropriately to all alleged violations.

0609Severity DOct 3, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0585Severity EOct 3, 2024

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.

0580Severity DOct 3, 2024

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0745Severity DJun 6, 2024

Provide medically-related social services to help each resident achieve the highest possible quality of life.

0880Severity DMay 14, 2024

Provide and implement an infection prevention and control program.

0849Severity DMay 14, 2024

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.

0812Severity FMay 14, 2024

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0761Severity DMay 14, 2024

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.

0760Severity DMay 14, 2024

Ensure that residents are free from significant medication errors.

0756Severity DMay 14, 2024

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0700Severity EMay 14, 2024

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.

0698Severity DMay 14, 2024

Provide safe, appropriate dialysis care/services for a resident who requires such services.

0693Severity DMay 14, 2024

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.

0690Severity DMay 14, 2024

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

0686Severity GMay 14, 2024

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0685Severity DMay 14, 2024

Assist a resident in gaining access to vision and hearing services.

0655Severity DMay 14, 2024

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

0644Severity DMay 14, 2024

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0609Severity DMay 14, 2024

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0559Severity EMay 14, 2024

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

0623Severity DNov 2, 2023

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0610Severity DNov 2, 2023

Respond appropriately to all alleged violations.

0609Severity DNov 2, 2023

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0838Severity ESep 14, 2023

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.

0740Severity GSep 14, 2023

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

0730Severity ESep 14, 2023

Observe each nurse aide's job performance and give regular training.

0610Severity ESep 14, 2023

Respond appropriately to all alleged violations.

0609Severity DSep 14, 2023

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0580Severity DSep 14, 2023

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0566Severity FSep 14, 2023

1) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.

View full inspection history on Medicare.gov

Civil Monetary Penalties

No civil monetary penalties on record.

Nearby Hospitals

No hospitals found within 10 miles.

Proximity to emergency care is especially important for medically complex residents.

Ownership

THE BAY AT BURLINGTON HEALTH AND REHABILITATION LLC· For profit - Limited Liability company

Data updated weekly from CMS. Last sync: Jun 26, 2026. Medicare.gov Care Compare →

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Data sourced from the Centers for Medicare & Medicaid Services and state licensing agencies. ← Back to search

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