Burgess Square Healthcare Ctr

Name: Burgess Square Healthcare Ctr
Address: 5801 SOUTH CASS AVENUE, Westmont, IL, 60559, US
Telephone: 6309712645

5801 South Cass Avenue, Westmont, IL 60559 · Du Page County · 203 certified beds · avg 123 residents/day · certified since May 7, 1970

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

4.74

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · May 21, 2026 · F-0686 · triggered by a complaint

The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jun 4, 2026 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Nov 20, 2025 · F-0760 · triggered by a complaint

The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Why it matters: A serious medication error can cause real harm, hospitalization, or worse.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Dec 3, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Mar 8, 2024 · F-0686 · triggered by a complaint

Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 26, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (29)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
May 21, 2026	▲ G · Actual harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Dec 4, 2025	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 4, 2025	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 4, 2025	E · Potential for harm, repeated	The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Dec 4, 2025	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Dec 4, 2025	D · Potential for harm, one-off	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
Nov 20, 2025	▲ G · Actual harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Feb 11, 2025	E · Potential for harm, repeated	The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint
Sep 27, 2024	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Sep 27, 2024	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Sep 27, 2024	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Sep 27, 2024	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Sep 27, 2024	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Sep 27, 2024	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Sep 27, 2024	D · Potential for harm, one-off	The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.
Sep 27, 2024	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Sep 27, 2024	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Mar 8, 2024	▲ G · Actual harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Mar 8, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Nov 16, 2023	E · Potential for harm, repeated	The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Nov 16, 2023	E · Potential for harm, repeated	The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Nov 16, 2023	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 16, 2023	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Nov 16, 2023	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Nov 16, 2023	D · Potential for harm, one-off	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Nov 16, 2023	D · Potential for harm, one-off	The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (9 → 8).

Year	Citations	Serious (G–L)	Worst severity that year
2023	7	0	E
2024	11	1	G ▲
2025	10	1	G ▲
2026	1	1	G ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Illinois avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	4.74	2.99	3.95	top 9% in Illinois; top 18% in the U.S.
Registered Nurse hours	1.63	0.63	0.69	top 4% in Illinois; top 3% in the U.S.
Weekend total nurse staffing	4.42	2.67	3.50	top 8% in Illinois; top 13% in the U.S.
Weekend RN hours (not acuity-adjusted)	1.42	0.56	0.48	top 3% in Illinois; top 2% in the U.S.
Total nursing staff turnover (%)	46.6	44.5	45.8	bottom 42% in Illinois; bottom 46% in the U.S.
RN turnover (%)	27.9	41.8	42.9	top 28% in Illinois; top 26% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.94, RN 1.70, weekend 4.60. Staffing rating: 5/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 2/5 · short-stay residents: 5/5

Who owns this facility

For profit - Partnership

Owner / manager	Type	Role	Stake	Since
Hensley, Michael	Individual	5% or Greater Direct Ownership Interest	26%	01/01/2012
Schreiber, Anthony	Individual	5% or Greater Direct Ownership Interest	30%	01/01/2012
Vrba, John	Individual	5% or Greater Direct Ownership Interest	44%	01/01/2012
Vrba, John	Individual	W-2 Managing Employee	NOT APPLICABLE	01/01/2012

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
"What systems do you use to prevent medication errors, and what happens when one occurs?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"How do you handle COVID-19 vaccination for residents and staff, and what happens during an outbreak?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Bria of Westmont	0.8 mi	Westmont, IL	★☆☆☆☆	1/5
Oak Trace	1.4 mi	Downers Grove, IL	★★★★★	4/5
Oakwood Rehab and Nursing Center	2.1 mi	Westmont, IL	★☆☆☆☆	1/5	abuse
Chateau Nrsg & Rehab Center	2.5 mi	Willowbrook, IL	★★☆☆☆	3/5
Eden Vista Burr Ridge	2.6 mi	Burr Ridge, IL	★★★★☆	4/5
Pearl of Hinsdale, the	2.7 mi	Hinsdale, IL	★★★★☆	4/5
The Pearl of Downers Grove	3.6 mi	Downers Grove, IL	★☆☆☆☆	2/5
Briar Place Nursing	4.4 mi	Indian Head Park, IL	★☆☆☆☆	2/5	abuse
Alta Rehab at Oak Brook	4.6 mi	Oak Brook, IL	★★☆☆☆	2/5
Bella Terra Lagrange	4.7 mi	La Grange, IL	★★★★☆	4/5
Beacon Hill	4.8 mi	Lombard, IL	★★★★★	4/5
Bella Terra Lombard	5.2 mi	Lombard, IL	★★★★☆	3/5

Compare this facility with the 3 closest →

All facilities in Westmont →

Facility data as of CMS processing date 2026-08-01. CCN 145219.

The Care File

Visit checklist — Burgess Square Healthcare Ctr

5801 South Cass Avenue, Westmont, IL 60559 · 6309712645

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $0

Most serious findings on record:

▲ May 21, 2026 (F-0686, Actual harm, one-off): The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
▲ Nov 20, 2025 (F-0760, Actual harm, one-off): The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
▲ Mar 8, 2024 (F-0686, Actual harm, one-off): The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.

Questions for the administrator:

☐ "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "How do you handle COVID-19 vaccination for residents and staff, and what happens during an outbreak?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 145219 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)