Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Citadel Of Bourbonnais,the during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and limited mobility was injured after rolling out of bed during care, as staff failed to implement the care plan's requirement for two quarter side rails to assist with bed mobility. The resident fell face-first onto the floor, sustaining a laceration that required 12 stitches, and staff interviews confirmed that the absence of side rails contributed to the incident.
The facility failed to maintain proper kitchen sanitation and food storage practices, affecting all 90 residents. Sanitization buckets and dishwashers were not maintained at correct concentration levels, and food storage areas contained expired and improperly stored items. Staff did not consistently follow hygiene protocols, with some observed without proper hair coverings. These deficiencies indicate a lack of adherence to food safety and hygiene protocols.
The facility failed to provide adequate ADL care to several residents, resulting in deficiencies in personal hygiene and grooming. Observations showed residents with long, unkempt nails and unmet requests for more frequent showers. Despite the facility's policy, the necessary assistance for personal hygiene was not consistently provided, impacting residents' dignity and safety.
Two residents with severe cognitive impairment were not provided dignified meal assistance. One resident was fed by staff standing over her, contrary to her care plan, while another ate with her hands due to lack of meal setup. The facility's policies on dignity and meal assistance were not adhered to.
A resident with severe cognitive impairment and a history of non-rheumatic aortic valve stenosis and dementia was not properly positioned during feeding in an adaptive wheelchair. Despite needing supervision and assistance, staff failed to reposition the resident for aspiration precautions, contrary to the facility's meal assistance policy.
A resident with lower extremity weakness did not receive restorative strengthening exercises as recommended by physical therapy. Despite a referral being made, the restorative nurse did not implement a strengthening program, and the resident reported not receiving assistance with leg exercises. The resident, who had multiple medical conditions and was at high risk for contractures, had no active restorative care plan, contrary to facility policy.
A resident with multiple health conditions experienced significant weight loss, and the facility failed to implement the dietician's recommendation for nutritional supplements. The oversight occurred because the new order was not entered into the system after the previous one was discontinued, resulting in the resident not receiving the necessary supplements.
The facility failed to follow infection control practices for enhanced barrier precautions, hand hygiene, and urinary drainage bag management. A CNA did not wear a gown while emptying a resident's catheter bag, which was placed on the floor, risking contamination. Another CNA did not perform hand hygiene between resident interactions and meal setups, violating the facility's hand hygiene policy.
The facility did not update the Daily Nursing Department Staffing Report, affecting all residents. The report was outdated during a survey, and the Scheduler, responsible for updating it, admitted to oversight after returning from vacation. The facility's policy mandates daily posting of staffing information, including the date.
Failure to Provide Required Bed Safety Measures During Resident Care
Penalty
Summary
A deficiency occurred when a resident who required maximum assistance with bed mobility was not safely turned during care, resulting in the resident rolling out of bed and sustaining a laceration to the forehead. The resident, who had severe cognitive impairment, functional limitations in both lower extremities, and a history of traumatic brain injury, was being cared for by a CNA alone. During a brief change, the resident was turned toward the left side, away from the CNA, and subsequently swung a leg over the bed edge, rolling out and falling face-first onto the floor. The resident was found lying between the bed and the wall, bleeding from the head, and was sent to the emergency room where 12 stitches were required for the forehead laceration. The care plan for this resident specified the use of two quarter side rails to assist with turning and repositioning in bed, and instructed staff to have the resident grab onto the side rail to aid in mobility. However, at the time of the incident, the bed did not have any side rails or other devices in place to prevent the resident from rolling out of bed. The CNA reported that the air mattress was flat and there were no side bolsters or bedrails attached to the bedframe. The CNA also stated that, because the resident was undressed during care, there was no way to safely grab and prevent the fall once the resident began to roll. Interviews with facility staff, including the Director of Nursing and the Nurse Practitioner, confirmed that the plan of care required the use of two quarter side rails for safety during bed mobility. Both acknowledged that the absence of these side rails at the time of care likely contributed to the resident's ability to roll out of bed and sustain injury. The incident was not attributed to a suicidal attempt by facility staff, despite a note in the hospital record, and the resident was described as cognitively impaired and not a reliable historian.
Deficiencies in Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to maintain its kitchen in a manner that prevents foodborne illness, affecting all 90 residents receiving dietary services. The Culinary Director, V20, confirmed that the sanitization bucket used in the kitchen was not maintained at the correct concentration levels, with a reading of 100 ppm instead of the required 150 to 400 ppm. Additionally, the dishwasher's sanitizer was found to be at 10 ppm, below the acceptable range of 50 to 100 ppm, due to a leak in the supply tubing. There were no logs documenting the sanitizer ppm, and the facility did not provide a specific policy for the sanitization buckets. The facility's dry storage and refrigeration practices were also found to be inadequate. Dented cans, expired food items, and improperly stored food were observed in the dry storage area. In the walk-in freezer and reach-in cooler, food items were found open to air, without labels or expiration dates, and some with visible freezer burn. The central nourishment room contained expired and unlabeled food items. The facility's policies on food storage and safety were not adhered to, as evidenced by the lack of proper labeling, dating, and storage of food items. Furthermore, the facility's staff did not consistently follow hygiene protocols. A Licensed Practical Nurse and kitchen staff were observed in the kitchen without proper hair coverings, contrary to the facility's Food Safety and Sanitization policy. Additionally, the unit refrigerator was found with excessive ice build-up, spills, and unlabeled food items. The responsibility for maintaining cleanliness and proper labeling was unclear, with housekeeping and nursing staff both mentioned as responsible parties. These deficiencies highlight a lack of adherence to established food safety and hygiene protocols, posing a risk of foodborne illness to the residents.
Deficiency in ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to five residents, resulting in deficiencies in personal hygiene and grooming. Observations revealed that several residents had long, jagged fingernails with brown substances underneath, indicating a lack of regular nail care. One resident, who had intact cognition, reported not receiving nail care for over a month, despite needing partial assistance due to diabetes and depression. Another resident, with moderate cognitive impairment and requiring substantial assistance, expressed a desire for more frequent showers, highlighting a gap in personal hygiene care. Additional observations included a resident with quadriplegia who required maximal assistance but was found with unkempt nails. Another resident, with cognitive impairment and multiple health conditions, had visible facial hair that was not addressed despite expressing a desire for its removal. The Director of Nursing acknowledged the importance of nail and skin care for safety, infection control, and dignity, yet the facility's policy on ADL care was not adequately implemented, as evidenced by the residents' conditions.
Failure to Provide Dignified Meal Assistance
Penalty
Summary
The facility failed to provide care with dignity to two residents, R70 and R38, during meal times. R70, who has severe cognitive impairment and requires supervision or touch assistance for eating, was observed being assisted by a CNA and the Assistant Director of Nursing while they stood over her, holding her bowl and spoon-feeding her. This approach did not align with R70's care plan, which indicated she should receive set-up help and supervision, allowing her to feed herself. The staff's actions did not promote a dignified dining experience for R70, as they did not adhere to the care plan's guidelines for providing assistance. Similarly, R38, who also has severe cognitive impairment and requires supervision or touch assistance for eating, was observed eating with her hands because her meal was not set up properly. Her meat patty was not cut, and her utensils remained wrapped, leading her to eat mashed potatoes with her fingers. A CNA observed this but did not assist R38, leaving her to continue eating without proper utensils. The Director of Nursing acknowledged that staff should not stand over residents while feeding them and should have provided meal setup for R38. The facility's policies emphasize treating residents with dignity and providing meal assistance that meets individual needs, which was not followed in these instances.
Failure to Properly Position Resident During Feeding
Penalty
Summary
The facility failed to properly position a resident, identified as R70, to maximize her eating abilities, which was observed during a lunch period. R70 was seen lying on her back in an adaptive wheelchair while being assisted with feeding by multiple staff members, including a CNA and the Assistant Director of Nursing. Despite the chair being in an upright position, R70's back and buttocks were on the seat of the chair, which was not conducive to safe eating practices. R70's medical history includes severe cognitive impairment, non-rheumatic aortic valve stenosis, and dementia, requiring supervision or touch assistance while eating. Her care plan indicated the need for supervision and assistance with meals, including aspiration precautions. However, during the observation, staff did not reposition R70 appropriately, as confirmed by the Director of Nursing, which was contrary to the facility's policy on assistance with meals that emphasizes safety, comfort, and dignity.
Failure to Provide Restorative Exercises Post-Therapy
Penalty
Summary
The facility failed to provide restorative strengthening exercises to a resident with weakness in both lower extremities, as recommended by physical therapy. The resident, who had been living in the facility for two months, reported not receiving any assistance with leg exercises despite expressing a desire for such help. The resident had previously received therapy for his hands and arms but not for his lower extremities. The physical therapy aide confirmed that a referral for strengthening exercises was made to the restorative aide upon the resident's discharge from skilled therapy. However, the restorative nurse stated she never received this referral and acknowledged that the resident was not receiving a strengthening program prior to the survey. The resident's medical history included diagnoses such as diabetes, acute respiratory failure with hypoxia, and peripheral vascular disease, among others. The resident was cognitively intact and at high risk for developing contractures, as noted in the facility's assessments. Despite these risks, there was no active restorative nursing care plan for range of motion or exercises. The facility's policy indicated that residents should receive restorative nursing care to promote safety and independence, but this was not implemented for the resident in question.
Failure to Implement Dietician's Nutritional Supplement Recommendations
Penalty
Summary
The facility failed to implement dietary supplements recommended by the dietician for a resident, identified as R31, who was readmitted with multiple diagnoses including cerebral infarction, type 2 diabetes, and congestive heart failure. R31 experienced a significant weight loss of over 5% in six months, which was a concern given his medical conditions. The dietician, V24, recommended a high-calorie, no-sugar supplement to be administered at noon and PM meals for 30 days, following R31's significant weight changes. However, this recommendation was not implemented as the order was not reentered into the system after the previous order was discontinued. The Clinical Nurse Manager, V25, acknowledged the oversight, stating that the dietician's recommendations were not updated in the care plan or communicated to dietary services to ensure the supplements were provided. As a result, R31 did not receive the prescribed nutritional supplements, and there was no physician-ordered diet in the Electronic Medical Record (EMR) since the diet orders were discontinued. This failure to provide the necessary dietary supplements was contrary to the facility's policy, which mandates that each resident is provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs.
Infection Control Deficiencies in Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to adhere to infection control practices concerning enhanced barrier precautions, hand hygiene, and urinary drainage bag management for three residents. In one instance, a Certified Nursing Assistant (CNA) was observed emptying a resident's indwelling catheter drainage bag while only wearing gloves, contrary to the facility's policy requiring both gown and gloves for such procedures. The resident had a history of salmonella in the urine and was on enhanced barrier precautions. Additionally, the CNA improperly placed the urinary drainage bag on the floor, risking contamination. The facility's policies clearly state the necessity of wearing gowns and gloves during high-contact activities and ensuring that catheter drainage bags are kept off the floor to prevent infection. In another instance, a CNA was observed failing to perform hand hygiene between resident interactions and meal setups. The CNA handled multiple residents' meals and personal items without cleaning her hands, which is against the facility's hand hygiene policy. The Director of Nursing confirmed that staff should clean their hands after resident contact and before handling food. The facility's hand hygiene policy emphasizes the importance of hand hygiene in preventing the spread of infections, requiring all personnel to follow procedures to prevent healthcare-associated infections.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to post the current date's staffing information for the Daily Nursing Department Staffing Report, affecting all 90 residents. On the day of the annual licensure and certification survey, the staffing report was found to be dated for the previous day. The Administrator confirmed that the Scheduler is responsible for updating and posting the daily staffing report, which should be visible to residents, visitors, and staff. The Scheduler admitted to not updating the report on the specified date due to being sidetracked after returning from vacation. The facility's policy requires daily posting of the number of nursing personnel responsible for direct care, including the date for which the information is posted.
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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 Bourbonnais
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Miller Health Care Center | 2.1 mi | ★★★★★ | 7 | 1 |
| Arc At Kankakee | 2.1 mi | ★★★★★ | 0 | 0 |
| Citadel Care Center-kankakee | 2.2 mi | ★★★★★ | 0 | 0 |
| Arc At Bradley | 2.3 mi | ★★★★★ | 3 | 0 |
| Momence Meadows Nursing & Rehab | 12.2 mi | ★★★★★ | 14 | 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 July 2026) and official state health department websites.