Burlington Health And Rehabilitation Center
Inspection Findings
F-Tag F0806
F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
roast was served to each of the residents. Some of the residents were observed being served carrots and some received mashed potatoes with gravy. A dinner roll was served with each meal. There were no additional vegetable or carbohydrate/starch alternates observed to be served or offered to any of the residents during the meal. During an observation and interview on 12/21/25 at 12:13 PM Resident R2 was observed eating her lunch in the dining room. The resident was served the pot roast with gravy, mashed potatoes, and a roll. The resident did not have any vegetables on her plate. Resident R2 confirmed she was not served any vegetables for lunch and stated the only vegetable option for the meal was carrots, and she did not eat carrots. Resident R2 stated, There is no different vegetable. They (the facility) used to have a whole list of things (food options) but they don't have that anymore. We eat what they bring us. Resident R2 stated she had not been offered an alternate vegetable for lunch when she stated she did not want the carrots indicated on the daily menu. During an observation on 12/22/25 at 11:36 AM the lunch meal had no alternate vegetable and no alternate starch observed to be served or offered to residents during the meal. During an interview on 12/22/25 at 11:36 AM with the Food Services Manager (FSM) she confirmed there was only one alternate main entree served each day, and it was the same alternate served for both lunch and dinner. She confirmed there was not an alternate vegetable or starch served with each meal. The FSM stated the Always Available Menu was expected to be posted next to the daily menus throughout the facility as well as
in each resident's room. The FSM further confirmed residents receiving special diets received the meal posted on the menu for each day and no alternate was available for those meals. During an interview on 12/22/25 at 12:55 PM with the Registered Dietician (RD) she confirmed her expectation was alternates were to be available for each meal of equal nutritive value to the original meal served. She stated she expected the menus, including the Always Available Menu to be posted were residents would have access to them. During an interview on 12/21/25 at 10:00 AM with the Resident Council, Resident R23 stated the alternative menu disappeared about a month (November 2025) ago. They no longer had the alternative choices to choose from. When Resident R23 asked why, staff informed her that it was too complicated for the staff in the kitchen. Resident R18 stated they added a new alternative, but it was the same food. He added if they were being served a chop salad the alternative would be a Caesar salad or a hamburger for a hamburger. Resident R18 stated staff does not offer alternatives if residents want something other than the main meal being served. Review of the facility's Menus and Adequate Nutrition Policy dated 06/26/25 revealed, The purpose of this guideline is to ensure menus are developed and prepared to meet resident choices, including their nutritional, religious, cultural, and ethnic needs; while using established guidelines; and Alternatives shall be immediately available if the primary menu or selections for a particular meal are not to a resident's liking.
Event ID:
Facility ID:
If continuation sheet
BURLINGTON HEALTH AND REHABILITATION CENTER in BURLINGTON, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BURLINGTON, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BURLINGTON HEALTH AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.