Safety Report: Burlington Health and Rehabilitation Center
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
Citations by topic
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (28) than in the cycle before (39).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Provide and implement an infection prevention and control program. (F880) | 5 | August 13, 2025; June 26, 2025; October 3, 2024; May 14, 2024; March 21, 2023 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609) | 5 | August 13, 2025; October 3, 2024; May 14, 2024; November 2, 2023; March 21, 2023 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 4 | June 18, 2026; August 13, 2025; October 3, 2024; March 21, 2023 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 4 | August 13, 2025; May 8, 2025; May 14, 2024; March 21, 2023 |
| Respond appropriately to all alleged violations. (F610) | 4 | August 13, 2025; October 3, 2024; November 2, 2023; March 21, 2023 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 3 | August 13, 2025; October 3, 2024; March 21, 2023 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686) | 3 | August 13, 2025; May 14, 2024; March 21, 2023 |
| Ensure that residents are free from significant medication errors. (F760) | 3 | May 8, 2025; October 3, 2024; May 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. (F761) | 2 | August 13, 2025; May 14, 2024 |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F600) | 2 | August 13, 2025; March 21, 2023 |
| 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. (F849) | 2 | August 13, 2025; May 14, 2024 |
| 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. (F803) | 2 | August 13, 2025; May 8, 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. (F700) | 2 | August 13, 2025; May 14, 2024 |
| Provide safe and appropriate respiratory care for a resident when needed. (F695) | 2 | August 13, 2025; October 3, 2024 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 2 | May 8, 2025; October 3, 2024 |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. (F698) | 2 | May 8, 2025; May 14, 2024 |
| Ensure each resident’s drug regimen must be free from unnecessary drugs. (F757) | 2 | October 3, 2024; March 21, 2023 |
| Provide enough food/fluids to maintain a resident's health. (F692) | 2 | October 3, 2024; March 21, 2023 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| May 14, 2024 | Payment Denial | Payment denial for 22 days, starting June 13, 2024 |
| May 14, 2024 | Fine | $86,790 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
June 18, 2026 — 2 citations · complaint investigation
December 22, 2025 — 1 citation · complaint investigation
August 13, 2025 — 25 citations
June 26, 2025 — 1 citation · complaint investigation
May 8, 2025 — 7 citations · complaint investigation
January 30, 2025 — 1 citation · complaint investigation
October 3, 2024 — 14 citations · complaint investigation
June 6, 2024 — 1 citation · complaint investigation
May 14, 2024 — 16 citations (includes serious)
November 2, 2023 — 5 citations (includes serious) · complaint investigation
March 21, 2023 — 14 citations (includes serious)
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare