Burgess Square Healthcare: Warfarin Overdoses Harm Residents - IL
The wrong dose had been entered into her records and then, according to the inspection, deleted, leaving staff to keep administering whatever was already in the system. Five days passed. The error compounded with each one.
Federal inspectors cited the facility for actual harm under the medication error tag, one of the more serious classifications available to CMS surveyors. The inspection was conducted November 20, 2025, and was triggered by a complaint.
A second resident, identified in the inspection record as R4, also received an incorrect Warfarin dose. On October 31, 2025, R4 received a total of 11 milligrams of the drug when that amount was wrong for her. By November 4, her INR had risen to 5.04.
INR, or International Normalized Ratio, measures how long it takes blood to clot. For most patients on Warfarin, clinicians target a range between 2.0 and 3.0, depending on the condition being treated. An INR of 5.04 doubles the bleeding risk that already comes with therapeutic anticoagulation. An INR of 13.10 is a medical emergency.
The inspection record attributes the findings in part to a nurse identified as V9, who told surveyors that R4 should not have received 11 milligrams on October 31, and that R4's elevated result five days later was a direct consequence of that overdose. V9 also told inspectors that the inaccurate administration of Warfarin to the first resident caused her INR to rise to 13.10, resulting in hospitalization and Vitamin K treatment.
Warfarin is one of the most commonly prescribed drugs in nursing homes and one of the most dangerous to get wrong. It has a narrow therapeutic window, meaning the difference between a dose that prevents a stroke and a dose that causes uncontrolled bleeding is often a matter of milligrams. Facilities that use it are expected to monitor INR levels closely and adjust doses carefully, because small errors accumulate fast.
What the inspection record describes is not a monitoring failure after a correct dose. It is a documentation failure that led directly to repeated incorrect dosing. The first resident's correct dose was entered and then deleted. No one restored it. No one flagged the discrepancy. The wrong amount was given on day one, day two, day three, day four, and day five.
By the time the error surfaced, her INR had reached a level at which spontaneous internal bleeding becomes a serious risk. Vitamin K can reverse Warfarin's effects, but the reversal is not immediate, and the hospitalization itself carries its own risks for a nursing home resident.
The inspection record does not describe what happened to either resident after treatment, whether the first resident recovered without lasting injury, or whether R4 required additional intervention beyond monitoring. It does not name either resident, does not specify their ages or underlying conditions, and does not describe what disciplinary action, if any, the facility took against the staff involved in the errors.
What it does say is that two residents were harmed, that both harms were caused by incorrect Warfarin dosing, and that a nurse who spoke to inspectors confirmed both errors and their consequences.
Burgess Square Healthcare Center is a skilled nursing facility in Westmont, a suburb roughly 20 miles west of Chicago. The complaint that triggered the November inspection is not described in the portion of the report made available, and it is not clear whether the complaints were filed by residents, family members, or staff.
The facility received an actual harm citation, not the more severe immediate jeopardy designation, which suggests inspectors did not find an ongoing and immediate threat to residents at the time of the survey. That distinction matters for enforcement purposes. It does not change what happened to the resident whose blood levels reached 13.10, or the five days it took for anyone to notice she had been receiving the wrong medication all along.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Burgess Square Healthcare Ctr from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 29, 2026 · Our methodology
BURGESS SQUARE HEALTHCARE CTR in WESTMONT, IL was cited for violations during a health inspection on November 20, 2025.
The error compounded with each one.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.