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
Registered name: CITADEL OF BOURBONNAIS,THE
BOURBONNAIS, IL · Medicare-certified · 107 beds
In good standing
For-profitChain member
Data as of July 1, 2026
3 of 5 overall
Citadel of Bourbonnais in Bourbonnais, IL has a 3-star overall rating. Its staffing is low at 1 star, with reported nurse staffing of 3.46 hours per resident per day below the 4.1 federal benchmark; health inspections are stronger at 4 stars, quality measures are 2 stars, and there were no fines in the last 24 months.
Facility ratings
Health inspections
Staffing
3.4586 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 3.4586.
Staffing detail
- Registered nurses
- 0.63
- Licensed practical nurses
- 0.93
- Nurse aides
- 1.90
- Weekend nursing
- 3.02
Hours per resident per day.
Total staff turnover: 58%
Registered nurse turnover: 50%
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
15.6%16.7%Worsening
Residents with a fall causing major injury
4.9%0%Improving
Residents with pressure ulcers (bedsores)
5%1.3%Improving
Residents with a urinary tract infection
0%0%No change
Residents who lost too much weight
15.7%7.6%Improving
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
0%4.5%Worsening
Residents whose ability to walk got worse
2.7%0%Improving
Long-stay residents on antianxiety or sleep medication
24.3%31.3%Worsening
Short-stay residents newly given an antipsychotic
2.8%0%Improving
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
33.3%9.7%Improving
Residents with depressive symptoms
100%98.6%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
78%87.5%Improving
Short-stay residents given the seasonal flu vaccine
—56.2%—
Short-stay residents given the pneumonia vaccine
52%70.8%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.
View the original federal record
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.
View the original federal record
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
Recent ownership change · Nov 1, 2020
Now operated by The Citadel of Bourbonnais, previously Presence Our Lady of Victory Nursing Home.
- Ownership
- For profit - Corporation
- Chain
- Part of CITADEL HEALTHCARE · 14 homes · 3.2 stars avg
- Occupancy
- 90.1 residents on an average day (84% 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.