Citadel of Bourbonnais,the
20 Briarcliff Lane, Bourbonnais, IL 60914 · Kankakee County · (815) 937-2022
107 certified beds, about 90 residents a day · For profit - Corporation · Medicare and Medicaid since 1986
Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
4 of 5
Staffing
1 of 5
Quality measures
2 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 145536 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on September 27, 2024, inspectors cited 8 health deficiencies (the Illinois average is 12.6, the national average 9.2).
Of 21 health citations since December 2022, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.46 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 0.63 of those hours.
58.1% of nursing staff left within the year CMS measured (Illinois average 44.5%).
CMS links it to Citadel Healthcare, an affiliated group of 16 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
812/22
311/23
112/23
809/24
110/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 21 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
12D
4E
2F
Potential for minimal harm
0A
0B
1C
October 7, 2025Complaint inspection · 1 citation
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who requires maximum assistance with bed mobility was turned safely during provision of care. This failure resulted in R1 rolling out of bed and landing with his face on the floor, sustaining a laceration to his left forehead. R1 was sent to the emergency room and received 12 stitches on his forehead. This applies to 1 of 3 residents (R1) reviewed for fall incidents in the sample of 3.
September 27, 2024Standard inspection · 8 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the facility's kitchen in a manner to prevent foodborne illness. This applies to all 90 residents in the facility receiving dietary services.
- E Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents. This applies to 5 residents (R7, R18, R47, R50, & R66) who were reviewed for activities of daily living in a sample of 22.
- D Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care with dignity to 2 residents (R38, R70) reviewed for dignity in a sample of 22.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly position 1 resident to maximize her eating abilities. This applies to (R50) who was reviewed for quality of life in a sample of 22.
- D Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to offer restorative strengthening exercises as recommended from physical therapy to a resident with weakness to both lower extremities who was discharged from skilled therapy. This applies to 1 of 1 resident (R88) reviewed for restorative nursing in a sample of 22.
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement dietary supplements recommended by the dietician. This applies to 1 of 2 residents (R31) reviewed for nutrition in a sample of 22.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for enhanced barrier precautions, hand hygiene, and urinary drainage bag management. This applies to 3 residents (R7, R22, R65) reviewed for infection control in a sample of 22.
- C Post nurse staffing information every day.
Inspectors wroteBased on observation, interview, and record review, the facility failed to post the current date's staffing for the Daily Nursing Department Staffing Report. This applies to all 90 residents in the facility.
December 29, 2023Complaint inspection · 1 citation
- G Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to transfer a resident safely from a shower chair. This failure resulted in R1 sustaining a left tibial fracture after a fall in the shower room. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3.
November 3, 2023Standard inspection · 3 citations
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to complete assessments for medication self-administration and failed to obtain orders to keep medications at the bedside. This applies to 2 of 3 residents (R8, R57) reviewed for medications in sample of 18.
- D Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Inspectors wroteBased on observation, interview, and record review, the facility failed to apply assistive devices to prevent contractures. This apples to 2 of 2 residents (R23, R34) reviewed for assistive devices in a sample of 18.
- D Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired food items, clean residents' refrigerators, provide refrigerator thermometers, and monitor daily temperatures. This applies to 3 of 3 residents (R15, R50, R72) reviewed for refrigerators in a sample of 18.
December 22, 2022Standard inspection · 8 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the dishes are washed in a clean and sanitary environment and failed to maintain sanitizing solutions in sanitation buckets within recommended sanitation concentrations. This applies to all 91 residents that receive oral diets from the facility kitchen.
- E Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and toilet use. This applies to 5 of 6 residents (R3, R31, R32, R49 and R54) reviewed for ADL (activities of daily living) in the sample of 22.
- E 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.
Inspectors wroteBased on observation, interview and record review, the facility failed to serve portion sizes for the mechanical soft diets as shown in the menu spread sheet for the lunch meal service. This applies to 4 of 5 residents (R10, R25, R39, R64) observed for dining in the sample of 22.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard infection control practices during provisions of care related to hand hygiene, gloving and proper use of mask. The facility also failed to ensure catheter tubing was not touching the floor. This applies to 4 of 5 residents (R19, R37, R44, R74) reviewed for infection control in the sample of 22.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to fasten a seat belt of a resident while providing transportation in facility's bus and failed to provide supervision resulting in the residents fall. This applies to 1 of 2 residents (R77) reviewed for fall incidents in the sample of 22.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide incontinence care and catheter care in a manner that would prevent infection and maintain hygiene. This applies to 3 of 3 residents (R37, R54 and R74) reviewed for incontinence care and urinary catheter care in the sample of 22.
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the rate of infusion of the gastrostomy tube (g-tube) feeding as prescribed by a physician to meet a resident's nutrition needs. This applies to 1 of 1 resident (R74) reviewed for enteral feeding in the sample of 22 residents.
- D Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered by a physician. There were 2 medication errors out of the 25 opportunities which resulted to 8% medication error rate. This applies to 1 of 7 residents (R44) reviewed for medication pass.
Fire safety inspections
20 fire safety citations on file: 8 on September 27, 2024, 5 on November 3, 2023, 7 on December 22, 2022.
Every fire safety citation20 citations
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- E Install proper backup exit lighting.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Install corridor and hallway doors that block smoke.
- E Install smoke barrier doors that can resist smoke for at least 20 minutes.
- E Meet requirements for the installation and maintenance of electrical systems.
- E Ensure proper usage of power strips and extension cords.
- F Install emergency lighting that can last at least 1 1/2 hours.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- E Install a fire alarm system that can be heard throughout the facility.
- E Install corridor and hallway doors that block smoke.
- E Install smoke barrier doors that can resist smoke for at least 20 minutes.
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Install corridor and hallway doors that block smoke.
- E Install smoke barrier doors that can resist smoke for at least 20 minutes.
- E Have restrictions on the use of portable space heaters.
- C Have simulated fire drills held at unexpected times.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Illinois | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.46 | 3.45 | 3.86 |
| Registered nurses | 0.63 | 0.72 | 0.69 |
| All nursing staff on weekends | 3.02 | 3.07 | 3.42 |
| Nurse aides | 1.90 | ||
| Licensed practical nurses | 0.93 | ||
| Nursing staff turnover (share who left in a year) | 58.1% | 44.5% | 45.8% |
| Registered nurse turnover | 50.0% | 41.8% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.95 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.64 on weekdays and 3.02 on weekends, 17% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 12.7% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.41 in April to June 2025 to 3.46 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.46 | 0.63 | 3.64 | 3.02 | 12.7% | 0 of 90 | 90 |
| Oct to Dec 2025 | 3.42 | 0.79 | 3.57 | 3.03 | 10.7% | 0 of 92 | 92 |
| Jul to Sep 2025 | 3.34 | 0.76 | 3.47 | 3.02 | 4.6% | 0 of 92 | 95 |
| Apr to Jun 2025 | 3.41 | 0.72 | 3.56 | 3.04 | 15.1% | 0 of 91 | 95 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Illinois, Jan to Mar 2026 | 3.26 | 0.65 | 3.40 | 2.92 | 5.4% | 0.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Illinois | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 4.7 | 13.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.8 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.6 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 1.9 | 14.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.7 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 17.4 | 21.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 26.8 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 15.8 | 13.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.5 | 2.0 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.8 | 2.2 | 1.8 |
Owners and operators
Legal business name: CITADEL OF BOURBONNAIS LLC. CMS links this home to Citadel Healthcare, a group of 16 nursing homes averaging 2.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ab Investment Trust U/a/D 01/03/23 | 5% or greater direct ownership interest | Organization | 10% | 11/01/2020 |
| Berger, Menachem | Direct ownership interest | Individual | 04/01/2023 | |
| Graf, Marcella | Direct ownership interest | Individual | 11/01/2020 | |
| Gross, Shoshana | Direct ownership interest | Individual | 04/01/2023 | |
| Proctor, Katherine | Direct ownership interest | Individual | 04/01/2023 | |
| Teller, Chananel | Direct ownership interest | Individual | 04/01/2023 | |
| Aaron, Jonathan | Corporate officer | Individual | 11/01/2020 | |
| Aaron, Jonathan | Operational/managerial control | Individual | 11/01/2020 | |
| Gifford, Robin | Operational/managerial control | Individual | 08/04/2022 | |
| Graf, Marcella | Operational/managerial control | Individual | 11/01/2020 | |
| Robin, Jason | Operational/managerial control | Individual | 05/01/2024 | |
| Berger, Menachem | Trustee of the SNF | Individual | 11/01/2020 | |
| 20 Briarcliff Lane LLC | Adp of the SNF | Organization | 02/17/2025 | |
| Ab Investment Trust U/a/D 01/03/23 | Adp of the SNF | Organization | 11/01/2020 | |
| Israel Family Investment Trust | Adp of the SNF | Organization | 11/01/2020 | |
| Israel Investment Tr | Adp of the SNF | Organization | 11/01/2020 | |
| Omnia Healthcare Group LLC | Adp of the SNF | Organization | 01/01/2024 | |
| Todd a Stern 2015 Irrv Ins Tr | Adp of the SNF | Organization | 11/01/2020 | |
| Aaron, Jonathan | Adp of the SNF | Individual | 11/01/2020 | |
| Berger, Menachem | Adp of the SNF | Individual | 11/01/2020 | |
| Gifford, Robin | Adp of the SNF | Individual | 08/04/2022 | |
| Graf, Marcella | Adp of the SNF | Individual | 11/01/2020 | |
| Gross, Shoshana | Adp of the SNF | Individual | 04/01/2023 | |
| Proctor, Katherine | Adp of the SNF | Individual | 04/01/2023 | |
| Robin, Jason | Adp of the SNF | Individual | 05/01/2024 | |
| Teller, Chananel | Adp of the SNF | Individual | 04/01/2023 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 11 problems in this area, most recently on October 7, 2025: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- Can we see a week of menus and the kitchen, and how are special diets handled?Inspectors cited 4 problems in this area, most recently on September 27, 2024: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 2 problems in this area, most recently on September 27, 2024: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
- What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 2 problems in this area, most recently on September 27, 2024: "Provide and implement an infection prevention and control program."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.02 hours per resident per day, below the Illinois average of 3.07.
Other nursing homes nearby
- Miller Health Care Center Kankakee, 2.1 mi · 2 of 5 stars · 34 citations
- Arc at Kankakee Kankakee, 2.1 mi · 3 of 5 stars · 16 citations
- Citadel Care Center-Kankakee Kankakee, 2.2 mi · 4 of 5 stars · 23 citations
- Arc at Bradley Bradley, 2.3 mi · 1 of 5 stars · 39 citations
- Momence Meadows Nursing & Rehab Momence, 12.2 mi · 1 of 5 stars · 55 citations
- La Bella at Clifton Clifton, 15.4 mi · 1 of 5 stars · 52 citations
- Aperion Care Wilmington Wilmington, 16 mi · 1 of 5 stars · 50 citations
- Beecher Manor Nrsg & Rehab Ctr Beecher, 19.9 mi · 2 of 5 stars · 40 citations
Illinois contacts for a concern about a nursing home
These are the official offices in Illinois. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Illinois Department of Public Health, Nursing Homes, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Illinois Long-Term Care Ombudsman Program, Illinois Department on Aging, 1-800-252-8966. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: IDPH Quarterly Reports of Nursing Home Violators, where Illinois publishes its own records on licensed homes.
Common questions
- What is Citadel of Bourbonnais,the's Medicare star rating?
- CMS rates Citadel of Bourbonnais,the 3 out of 5 stars overall, with 4 for health inspections, 1 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Citadel of Bourbonnais,the get at its last inspection?
- 8 health deficiencies at the standard inspection on September 27, 2024. The Illinois average is 12.6.
- Has Citadel of Bourbonnais,the been fined?
- CMS lists no fines in the last three years.
- Does Citadel of Bourbonnais,the accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Citadel of Bourbonnais,the?
- CMS lists 26 owners and managers, and links the home to Citadel Healthcare. Legal business name: CITADEL OF BOURBONNAIS LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.