Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Burgess Square Healthcare Ctr during CMS and state inspections, most recent first.
A temporary agency CNA was found responsible for the theft of credit cards and cash from multiple residents in the facility. Unauthorized charges were made on the stolen cards, and one resident was contacted by the CNA for money due to personal hardships. The facility's investigation linked the thefts to the CNA, who was assigned to the affected residents' rooms during the incidents.
The facility failed to safely reposition a resident with multiple health issues, as a CNA improperly pulled the resident by the arm without assistance, against policy. Additionally, oxygen tanks were found unsecured in residents' rooms, posing a tipping hazard, despite the facility's policy requiring them to be secured.
The facility failed to safely store medications for five residents, leading to deficiencies in medication management. Medications were found loose and unlabeled on a medication cart, and unauthorized medications were stored at residents' bedsides without proper orders. The facility's policies on secure and labeled medication storage were not followed.
The facility failed to follow infection control practices for residents on transmission-based precautions, affecting five residents. Staff, including CNAs and housekeeping, did not consistently wear required PPE such as gowns and gloves during high-contact activities, despite clear signage and facility policies. This non-compliance was observed in residents with conditions like MDRO, MRSA, and those with indwelling medical devices, highlighting a significant lapse in infection prevention protocols.
The facility failed to ensure IV medications were administered by qualified staff, involving three residents receiving IV therapy. An LPN administered Ceftriaxone and Ertapenem through PICC lines, despite regulations indicating LPNs should not initiate IV medications through midline or central lines. Another LPN confirmed she would not perform such tasks, highlighting a discrepancy in practice. The facility's policy and state regulations both indicate that LPNs should not perform these tasks, pointing to a failure in adhering to professional standards of quality care.
Two residents with urinary catheters received improper care, including inadequate cleaning techniques and unsecured drainage bags. One resident's catheter tubing was obstructed, and the drainage bag was placed on the floor. Another resident's catheter and genital area were cleaned with the same washcloth. The DON confirmed the facility's catheter care policy was not followed.
A resident's PEG tube placement was not properly verified before medication administration, and the nurse failed to follow physician orders for water flushes and medication dilution, risking gastrointestinal irritation.
The facility failed to maintain proper care for two residents with PICC lines, as their dressings were not changed according to physician orders and facility policy. One resident's dressing was soiled and unchanged for days, while another's dressing was not updated for over a week. The Director of Nursing acknowledged the oversight, citing a missed change due to a hospital visit.
A resident with multiple health conditions was receiving oxygen without a physician's order, contrary to the facility's policy. Observations showed the resident receiving 3.5 to 4 liters of oxygen via nasal cannula, but the Physician Order Sheet lacked the necessary order. Staff confirmed the requirement for a physician's order for oxygen, which was not obtained.
The facility failed to accurately log and dispose of controlled medications for two residents. An LPN improperly stored medication documentation and pre-pulled medications against policy. The DON confirmed the need for proper documentation and storage.
Misappropriation of Resident Property by Temporary CNA
Penalty
Summary
The facility failed to prevent the misappropriation of resident property, as evidenced by multiple incidents involving the theft of credit cards and cash from residents. The investigation revealed that a temporary agency CNA, identified as V4, was responsible for the thefts. This CNA was assigned to the rooms of the affected residents during the time the items went missing, and unauthorized charges were made near V4's home. The facility's initial investigation identified multiple residents missing credit cards, and further investigation linked the thefts to V4. One resident, R1, discovered unauthorized charges on her credit card after being contacted by a convenience store. Upon checking her belongings, she found her credit and debit cards missing. R1's daughter reported the unauthorized use to the facility, and the administrator assisted in canceling the card and filing a police report. Similarly, R2 noticed unauthorized charges on her account and reported missing cards and cash. R4 also reported missing a credit card and cash, with unauthorized charges appearing on her account. R3, after hearing about her roommate's missing items, discovered cash missing from her drawer. Additionally, R6 was contacted by V4 via text message, where V4 requested money due to personal hardships. This contact was reported to the police by the administrator. The facility's abuse prevention policy states that residents should be free from misappropriation of property, which includes the wrongful use of a resident's belongings or money without consent. The facility's failure to prevent these incidents constitutes a deficiency in protecting residents from misappropriation of property.
Unsafe Repositioning and Unsecured Oxygen Tanks
Penalty
Summary
The facility failed to ensure safe repositioning of a resident and secure oxygen tanks, leading to potential accident hazards. A resident with multiple diagnoses, including Parkinson's disease and dementia, was improperly repositioned by a CNA who pulled the resident by the upper arm without assistance, contrary to the facility's policy requiring two staff members and a draw sheet. This action was observed by other staff members who confirmed that the correct procedure was not followed, potentially risking injury to the resident. Additionally, the facility did not secure oxygen tanks properly, posing a risk of them tipping over. Oxygen tanks were found unsecured in the rooms of residents with respiratory conditions, such as acute and chronic respiratory failure. Despite being observed on multiple occasions, the tanks remained unsecured, which was acknowledged by the facility's staff as a safety concern. The facility's policy requires that portable oxygen containers be protected from falling over, which was not adhered to in these instances.
Medication Storage Deficiencies in LTC Facility
Penalty
Summary
The facility failed to safely store medications for five residents, leading to deficiencies in medication management. For one resident, medications were found loose in an unlabeled cup on a medication cart, and the nurse was unsure of their identity or ownership. The Director of Nursing confirmed that medications should be prepared at the time of administration and not stored in the cart once removed from their original packaging. Another resident had unauthorized medications, including eye drops and an inhaler, stored at their bedside without proper orders. The resident admitted to using these medications, which were not prescribed or approved for bedside storage. Similarly, a third resident had a nebulizer treatment and an inhaler in their room, brought by a family member, without the facility's knowledge or proper orders. Additional residents were found with unlabeled medications, such as glucose tablets and creams, at their bedside without orders for self-administration or bedside storage. The Director of Nursing stated that no residents had orders for bedside medication storage or self-administration, and any medications brought by family should be handled by nursing staff. The facility's policies require medications to be stored securely and labeled correctly, which was not adhered to in these cases.
Infection Control Deficiencies in PPE Use
Penalty
Summary
The facility failed to adhere to infection control practices for residents on transmission-based precautions, affecting five residents. One resident, admitted with a urinary tract infection and MDRO, was on contact isolation. Despite signage and available PPE, a CNA was observed providing care without wearing a gown, contrary to the facility's policy requiring gowns, gloves, and masks for contact precautions. Similarly, another resident with an unstageable pressure ulcer and MRSA infection was under Enhanced Barrier Precautions (EBP), yet an LPN did not wear a gown while performing IV maintenance, violating the requirement for gown and gloves during direct contact. Another resident, with diagnoses including COPD and dementia, was under EBP, but a housekeeping staff member only wore gloves while changing linens, disregarding the need for a gown. This staff member also mishandled dirty linen, placing it on the ground and against her clothing, which is against infection control protocols. Additionally, a resident with a urinary catheter was under EBP, but a CNA provided catheter care without performing hand hygiene or wearing a gown, and a housekeeping staff member also failed to wear a gown while changing bed sheets, despite clear signage. The facility's policies and signage clearly outlined the need for PPE, including gowns and gloves, during high-contact activities for residents under EBP. However, staff consistently failed to comply with these protocols, as evidenced by the observations of care provided to residents with indwelling medical devices and those at risk for infections. The Director of Nursing confirmed the expectations for PPE use, emphasizing the importance of proper hand hygiene and PPE to prevent infection transmission, yet these practices were not consistently followed by the staff.
Unqualified Staff Administering IV Medications
Penalty
Summary
The facility failed to ensure that intravenous medications were administered by qualified staff, specifically involving three residents receiving IV therapy. Resident R426 had an order for Ceftriaxone Sodium injection to be administered intravenously. On September 25, 2024, an LPN administered the medication through a PICC line, despite the Illinois Nurses Act indicating that LPNs are not permitted to initiate IV medications through midline or central lines. The Director of Nursing confirmed that LPNs were trained by RNs to administer IV medications, including antibiotics. Resident R324, with a history of an unstageable pressure ulcer and infections, was administered Ertapenem by an LPN on two occasions. The LPN described the process of administering the IV antibiotics, which included flushing the PICC line and checking for blood return. Similarly, Resident R321, who had a PICC line for surgical aftercare, received Sodium Chloride IV fluids administered by an LPN. Another LPN stated that she would not hang IVs as it was outside her scope of practice, highlighting a discrepancy in practice among staff. The facility's policy and the Illinois Nurses Act both indicate that LPNs should not perform these tasks, pointing to a failure in adhering to professional standards of quality care.
Improper Catheter Care and Hygiene Practices
Penalty
Summary
The facility failed to provide proper catheter care for two residents, leading to deficiencies in infection control and hygiene practices. One resident, with diagnoses of urinary retention and urinary tract infection, was observed not receiving catheter care after a bowel movement, and their catheter drainage bag was placed on the floor. Later, the same resident's catheter tubing was found underneath their thigh, causing obstruction, and the catheter was improperly cleaned with multiple upstrokes towards the urethra. The catheter drainage bag was left unsecured, hanging over the side of the bed. Another resident, also with urinary retention and neuromuscular dysfunction of the bladder, was observed receiving improper catheter care. The CNA used a single washcloth to clean the catheter with multiple upward and downward strokes and then used the same washcloth to clean the resident's genital area before returning to the catheter. The Director of Nursing confirmed that catheter care should be provided every shift and during incontinence care, with catheters cleaned away from the urethra and drainage bags kept off the floor and secured.
Improper PEG Tube Medication Administration
Penalty
Summary
The facility failed to properly verify the placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube before administering medications to a resident, identified as R171. During the medication administration process, a registered nurse (RN) used a stethoscope to auscultate the abdomen after injecting air through the PEG tube, but did not check the gastric content to confirm the tube's placement. This method of verification was not in accordance with the facility's guidelines, which require checking the gastric content to ensure proper tube placement. Additionally, the RN did not adhere to the physician's orders regarding the administration of water flushes and medications through the PEG tube. The RN administered 60 ml of water flush before and after medication administration, and 20 ml between each medication, which deviated from the prescribed 30 ml flush before and after, and 10-15 ml between medications. Furthermore, the RN failed to dilute the liquid Potassium Chloride as required by the manufacturer's guidelines, which could lead to gastrointestinal irritation. The Director of Nursing confirmed that the nurse should have followed the physician's orders and diluted the medication appropriately.
Failure to Maintain PICC Line Care
Penalty
Summary
The facility failed to provide appropriate care for residents with PICC lines, as evidenced by observations and record reviews. One resident had a PICC line with a transparent dressing that was soiled with dry blood and lacked a date, despite physician orders for daily care and dressing changes every Friday or as needed. The dressing remained unchanged and soiled over consecutive days, indicating a failure to adhere to the prescribed care plan. Another resident's PICC line dressing was not changed for over a week, despite facility policy requiring weekly changes or sooner if the dressing is compromised. The Director of Nursing acknowledged that the dressing should have been changed and attributed the oversight to the resident's hospital visit. The facility's policy emphasizes the importance of sterile dressing changes and regular assessments to prevent catheter-related infections, which were not followed in these cases.
Failure to Obtain Physician Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for oxygen administration for a resident who was receiving oxygen. The resident, who was admitted with multiple diagnoses including hypertensive encephalopathy, type 2 diabetes mellitus, and dementia, was observed receiving between 3.5 to 4 liters of oxygen via nasal cannula on two separate occasions. Despite this, the resident's Physician Order Sheet did not include an order for oxygen administration. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that residents receiving oxygen should have a physician's order, which was not present in this case. The facility's Oxygen Management Policy also mandates a physician order for oxygen administration, which was not adhered to in this instance.
Controlled Medication Handling Deficiencies
Penalty
Summary
The facility failed to ensure the accuracy of controlled medication counting logs and proper disposal of controlled medications for two residents. For one resident, the Controlled Substances Proof of Use sheet was improperly stored inside the controlled box rather than in the narcotic control counting log binder. The sheet lacked essential information such as the medication name, dosage, and administration instructions. Additionally, there were discrepancies in the packaging of the medication, with one package unsealed and containing a loose half tablet. For another resident, the Controlled Substance Proof of Use sheet was also stored incorrectly and did not include the ordered medication administration instructions. Furthermore, there was no active order for the medication found in the resident's records. The LPN admitted to pre-pulling controlled medications from the facility's narcotic convenience box, which is against the facility's policy. The Director of Nursing confirmed that all controlled substance documentation should be kept in the narcotic control sign-off binder and that medications should not be pre-pulled or improperly stored.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Westmont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bria Of Westmont | 0.9 mi | — | 11 | 0 |
| Oak Trace | 1.4 mi | — | 6 | 0 |
| Oakwood Rehab And Nursing Center | 2.1 mi | — | 14 | 0 |
| Chateau Nrsg & Rehab Center | 2.5 mi | — | 2 | 0 |
| Eden Vista Burr Ridge | 2.6 mi | — | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.