Burlington Health And Rehabilitation Center
Burlington Health and Rehabilitation Center in BURLINGTON, WI — inspection on December 22, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an observation and interview on 12/21/25 at 12:13 PM 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. 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. 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. 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, R23 stated the alternative menu disappeared about a month (November 2025) ago.
They no longer had the alternative choices to choose from.
When R23 asked why, staff informed her that it was too complicated for the staff in the kitchen. 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. 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.
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