Cycle 1
Health 2024-09-27 · Fire 2024-09-27
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Westmont, IL
Burgess Square Healthcare Ctr
5-star overall rating with 4-star inspections with 10 recent health deficiencies
5801 South Cass Avenue, Westmont, IL
(630) 971-2645
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
203
Certified beds
Average residents
126
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1970-05-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.46
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.58
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.70
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
2.12
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
4.31
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.15
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.41
CMS adjusted RN staffing hours
Adjusted total hours
4.54
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,399
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9976
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.87
Baseline 18.19% · Performance 19.18% · Measure score 4.87 · Achievement 4.87 · Improvement 0
Healthcare-associated infections
3.18
Baseline 6.20% · Performance 6.88% · Measure score 3.18 · Achievement 3.18 · Improvement 0
Total nurse turnover
5.19
Baseline 33.33% · Performance 42.48% · Measure score 5.19 · Achievement 5.19 · Improvement 0
Adjusted total nurse staffing
4.56
Baseline 4.06 hours · Performance 4.38 hours · Measure score 4.56 · Achievement 4.56 · Improvement 1.35
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.36% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 1112 · Observed rate 9.35% · Lower 95% interval 8.78% |
| Discharge to community | 62.32% |
50.57%
11.8 pts better
|
Better than the National Rate · Eligible stays 1095 · Observed rate 59.45% · Lower 95% interval 59.91% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.59% |
95.27%
3.3 pts better
|
Numerator 771 · Denominator 782 |
| Falls with major injury | 0.51% |
0.77%
0.3 pts better
|
Numerator 4 · Denominator 782 |
| Discharge self-care score | 71.5% |
53.69%
17.8 pts better
|
Numerator 414 · Denominator 579 |
| Discharge mobility score | 59.07% |
50.94%
8.1 pts better
|
Numerator 342 · Denominator 579 |
| Pressure ulcers or injuries, new or worsened | 4.99% |
2.29%
2.7 pts worse
|
Numerator 39 · Denominator 782 · Adjusted rate 4.94% |
| Healthcare-associated infections requiring hospitalization | 6.88% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 706 · Observed rate 5.81% · Lower 95% interval 5% |
| Staff COVID-19 vaccination coverage | 2.15% |
8.2%
6 pts worse
|
Numerator 6 · Denominator 279 |
| Staff flu vaccination coverage | 86.14% |
42%
44.1 pts better
|
Numerator 379 · Denominator 440 |
| Discharge function score | 64.77% |
56.45%
8.3 pts better
|
Numerator 375 · Denominator 579 |
| Transfer of health information to provider | 99.3% |
95.95%
3.3 pts better
|
Numerator 710 · Denominator 715 |
| Transfer of health information to patient | 91.67% |
96.28%
4.6 pts worse
|
Numerator 33 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 83 · Denominator 415 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
2.3
2 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
89.6%
7.8 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 94.7% · Q3 97.1% · Q4 100.0% · 4Q avg 97.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.3%
2 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.1% |
50.3%
48.2 pts better
|
11.4%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 2.9% · Q3 2.9% · Q4 0.0% · 4Q avg 2.1% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
6.5%
1.8 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.5% · Q3 6.9% · Q4 13.3% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.2% |
18.5%
4.3 pts better
|
19.6%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 15.2% · Q3 13.8% · Q4 11.8% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.3% |
22.8%
1.5 pts better
|
16.7%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 17.9% · Q3 23.1% · Q4 23.1% · 4Q avg 21.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.2% |
17.2%
6 pts worse
|
16.3%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.9% |
15.0%
0.9 pts worse
|
14.9%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 24.1% · Q3 16.0% · Q4 19.4% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
1.1%
1.7 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 3.9% · Q4 6.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.5% |
1.7%
3.8 pts worse
|
1.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.3% · Q3 5.7% · Q4 0.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.2% |
21.3%
15.9 pts worse
|
19.8%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 46.8% · Q2 39.6% · Q3 32.6% · Q4 26.8% · 4Q avg 37.2% |
| Percentage of long-stay residents with pressure ulcers | 9.1% |
5.2%
3.9 pts worse
|
5.1%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 10.6% · Q3 9.0% · Q4 8.7% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
68.8%
23.6 pts better
|
81.7%
10.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 93.3% · Q3 92.6% · Q4 91.8% · 4Q avg 92.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
14.0%
6 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 6.8% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
2.3%
1.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.1% · Q3 1.1% · Q4 0.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.2% |
63.0%
27.2 pts better
|
79.7%
10.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
26.2%
1.8 pts better
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 21.9% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-27 · Fire 2023-01-27
3 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
G · Actual harm
2025-11-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-03
E · Potential for more than minimal harm
2025-02-11
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-02-26
E · Potential for more than minimal harm
2024-09-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-27
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-27
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-27
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-09-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-10
G · Actual harm
2024-03-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-26
D · Potential for more than minimal harm
2024-03-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-26
E · Potential for more than minimal harm
2023-11-16
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-11-16
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-11-28
E · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-16
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-11-16
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-11-28
D · Potential for more than minimal harm
2023-07-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-01-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-14
D · Potential for more than minimal harm
2023-01-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-02-14
Penalties and ownership
What sits behind the stars
Ownership
Vrba, John
5% Or Greater Direct Ownership Interest · Individual
Schreiber, Anthony
5% Or Greater Direct Ownership Interest · Individual
Hensley, Michael
5% Or Greater Direct Ownership Interest · Individual
Vrba, John
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Bria Of Westmont
Westmont, IL
1-star overall rating with 1-star inspections with $151,077 in total fines with 23 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Oak Trace
Downers Grove, IL
5-star overall rating with 4-star inspections with $13,780 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Oakwood Rehab and Nursing Center
Westmont, IL
1-star overall rating with 2-star inspections with abuse icon flag with $49,439 in total fines with 24 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
Jump out