The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited October 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
CITADEL OF BOURBONNAIS,THE
BOURBONNAIS, IL · Medicare-certified · 107 beds
In good standing
For-profitChain member
4 of 5 overall
Citadel of Bourbonnais has an overall rating of 4 out of 5 stars, with a 4-star health inspection rating but weaker staffing and quality measure ratings at 2 stars each. Reported nurse staffing is 3.42 hours per resident per day, below the federal benchmark of 4.1, and there were $0 in fines over the last 24 months.
Facility ratings
Health inspections
Staffing
3.416 hrs/resident/day
Quality measures
Last inspection: October 7, 2025Penalties, last 24 months: $0
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.416.
Staffing detail
- Registered nurses
- 0.79
- Licensed practical nurses
- 0.68
- Nurse aides
- 1.95
- Weekend nursing
- 3.03
Hours per resident per day.
Total staff turnover: 47%
Registered nurse turnover: 35%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
24.6%19.6%Improving
Residents with a fall causing major injury
2.6%1.2%Improving
Residents with pressure ulcers (bedsores)
6%2.8%Improving
Residents with a urinary tract infection
0%0%No change
Residents who lost too much weight
19.4%11.3%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
7.4%9.2%Worsening
Residents whose ability to walk got worse
3.7%0%Improving
Long-stay residents on antianxiety or sleep medication
20.6%26.2%Worsening
Short-stay residents newly given an antipsychotic
0%0%No change
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
16.6%12.5%Improving
Residents with depressive symptoms
100%98.7%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—90.5%—
Long-stay residents given the pneumonia vaccine
76.3%82.7%Improving
Short-stay residents given the seasonal flu vaccine
—56.2%—
Short-stay residents given the pneumonia vaccine
53.2%67.4%Improving
What the inspectors found
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited September 2024 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The nursing home failed to provide needed care and help with daily activities for residents who could not do them on their own. Cited September 2024 — limited pattern, potential for harm.
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F-Tag 677 — 42 CFR §483.24(a)(2) — S/S: E
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited December 2022 — limited pattern, potential for harm.
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F-Tag 880 — 42 CFR §483.80(a) — S/S: E
The home failed to ensure meals and menus were planned, updated, and followed to meet residents’ nutritional needs. Cited December 2022 — limited pattern, potential for harm.
View the original federal record
F-Tag 803 — 42 CFR §483.60 — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 8 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of CITADEL HEALTHCARE · 13 homes · 3.5 stars avg
- Occupancy
- 91.9 residents on an average day (86% of 107 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 40 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.