Independent · Federal inspection records, searchable
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Nursing Home Violations Public inspection data, searchable
Facility profile · CCN 525482

Burlington Health And Rehabilitation Center

95 federal citations on record , including 6 at the Immediate Jeopardy level, and 5 federal enforcement actions totaling $414,369.

Special Focus Status 6 Immediate Jeopardy

Record summary

Federal record · Q1 2026
95
Total citations
81
Last 3 years
8
Actual harm+
5
Federal penalties
$414,369
Total fines
1
Overall ★ rating

Most common violation categories here

Quality of Care28 Abuse & Neglect15 Resident Rights12 Medication & Pharmacy12 Nutrition & Dietary8

Most common F-tags at this facility

F6096 F8805 F6105 F8124 F6894

Citation history

95 on record
SurveyF-TagViolationSeveritySource
Dec 22, 2025F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.DComplaint
Aug 13, 2025F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.FComplaint
Aug 13, 2025F880Provide and implement an infection prevention and control program.FComplaint
Aug 13, 2025F851Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.FComplaint
Aug 13, 2025F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FComplaint
Aug 13, 2025F803Ensure 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.DComplaint
Aug 13, 2025F697Provide safe, appropriate pain management for a resident who requires such services.DComplaint
Aug 13, 2025F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint
Aug 13, 2025F688Provide 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.DComplaint
Aug 13, 2025F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.DComplaint
Aug 13, 2025F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.EComplaint
Aug 13, 2025F677Provide care and assistance to perform activities of daily living for any resident who is unable.EComplaint
Aug 13, 2025F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Aug 13, 2025F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.EComplaint
Aug 13, 2025F584Honor 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.DComplaint
Aug 13, 2025F561Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.DComplaint
Aug 13, 2025F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.DComplaint
Aug 13, 2025F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.DStandard
Aug 13, 2025F761Ensure 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.EStandard
Aug 13, 2025F700Try 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.DStandard
Aug 13, 2025F695Provide safe and appropriate respiratory care for a resident when needed.DStandard
Aug 13, 2025F645PASARR screening for Mental disorders or Intellectual DisabilitiesDStandard
Aug 13, 2025F641Ensure each resident receives an accurate assessment.EStandard
Aug 13, 2025F610Respond appropriately to all alleged violations.DStandard
Aug 13, 2025F578Honor 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.DStandard
Aug 13, 2025F576Ensure residents have reasonable access to and privacy in their use of communication methods.FStandard
Jun 26, 2025F880Provide and implement an infection prevention and control program.DComplaint
May 8, 2025F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FComplaint
May 8, 2025F803Ensure 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.FComplaint
May 8, 2025F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.FComplaint
May 8, 2025F760Ensure that residents are free from significant medication errors.DComplaint
May 8, 2025F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.DComplaint
May 8, 2025F698Provide safe, appropriate dialysis care/services for a resident who requires such services.DComplaint
May 8, 2025F554Allow residents to self-administer drugs if determined clinically appropriate.DComplaint
Jan 30, 2025F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.EComplaint
Oct 3, 2024F880Provide and implement an infection prevention and control program.DComplaint
Oct 3, 2024F760Ensure that residents are free from significant medication errors.DComplaint
Oct 3, 2024F759Ensure medication error rates are not 5 percent or greater.DComplaint
Oct 3, 2024F757Ensure each resident’s drug regimen must be free from unnecessary drugs.DComplaint
Oct 3, 2024F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.EComplaint
Oct 3, 2024F695Provide safe and appropriate respiratory care for a resident when needed.DComplaint
Oct 3, 2024F692Provide enough food/fluids to maintain a resident's health.DComplaint
Oct 3, 2024F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint
Oct 3, 2024F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Oct 3, 2024F661Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.DComplaint
Oct 3, 2024F610Respond appropriately to all alleged violations.EComplaint
Oct 3, 2024F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Oct 3, 2024F585Honor 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.EComplaint
Oct 3, 2024F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Jun 6, 2024F745Provide medically-related social services to help each resident achieve the highest possible quality of life.DComplaint
May 14, 2024F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.GComplaint
May 14, 2024F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
May 14, 2024F880Provide and implement an infection prevention and control program.DStandard
May 14, 2024F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.DStandard
May 14, 2024F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
May 14, 2024F761Ensure 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.DStandard
May 14, 2024F760Ensure that residents are free from significant medication errors.DStandard
May 14, 2024F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.DStandard
May 14, 2024F700Try 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.EStandard
May 14, 2024F698Provide safe, appropriate dialysis care/services for a resident who requires such services.DStandard
May 14, 2024F693Ensure 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.DStandard
May 14, 2024F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.DStandard
May 14, 2024F685Assist a resident in gaining access to vision and hearing services.DStandard
May 14, 2024F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedDStandard
May 14, 2024F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.DStandard
May 14, 2024F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.EStandard
Nov 2, 2023F841Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.JComplaint
Nov 2, 2023F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.JComplaint
Nov 2, 2023F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.DComplaint
Nov 2, 2023F610Respond appropriately to all alleged violations.DComplaint
Nov 2, 2023F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Sep 14, 2023F838Conduct 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.EComplaint
Sep 14, 2023F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.GComplaint
Sep 14, 2023F730Observe each nurse aide's job performance and give regular training.EComplaint
Sep 14, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.JComplaint
Sep 14, 2023F678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.KComplaint
Sep 14, 2023F610Respond appropriately to all alleged violations.EComplaint
Sep 14, 2023F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Sep 14, 2023F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.JComplaint
Sep 14, 2023F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.DComplaint
Sep 14, 2023F5661) Protect residents from being forced to work at the nursing home, or 2) let residents work if they want to.FComplaint
Mar 21, 2023F692Provide enough food/fluids to maintain a resident's health.DComplaint
Mar 21, 2023F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.DComplaint
Mar 21, 2023F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.JComplaint
Mar 21, 2023F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.DComplaint
Mar 21, 2023F610Respond appropriately to all alleged violations.DComplaint
Mar 21, 2023F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.DComplaint
Mar 21, 2023F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.DComplaint
Mar 21, 2023F883Develop and implement policies and procedures for flu and pneumonia vaccinations.DStandard
Mar 21, 2023F880Provide and implement an infection prevention and control program.FStandard
Mar 21, 2023F838Conduct 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.FStandard
Mar 21, 2023F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.FStandard
Mar 21, 2023F758Implement 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.DStandard
Mar 21, 2023F757Ensure each resident’s drug regimen must be free from unnecessary drugs.EStandard
Mar 21, 2023F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.EStandard

Federal enforcement history

Federal regulators have imposed 5 enforcement actions against this facility, including 3 civil money penalties totaling $414,369 and 2 payment-denial actions spanning 75 days.

DateTypeFinePayment denial
May 14, 2024Fine$86,790—
May 14, 2024Payment Denial—Jun 13, 2024 · 22 days
Sep 14, 2023Fine$285,068—
Sep 14, 2023Payment Denial—Oct 14, 2023 · 53 days
Mar 21, 2023Fine$42,511—
About this record A citation is a finding by a state survey team working under federal contract. It is not a court judgment. The description above is drawn verbatim from federal public datasets. Facilities have the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.

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