Cycle 1
Health 2024-09-27 · Fire 2024-09-27
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Bourbonnais, IL
Citadel Of Bourbonnais,the
4-star overall rating with 4-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
20 Briarcliff Lane, Bourbonnais, IL
(815) 937-2022
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
95
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Citadel Healthcare
Operator or chain grouping
Approved since
1986-01-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 3 overall / 4 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.34
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
2.57
CMS adjusted total nurse staffing hours
Case-mix index
1.78
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,806
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.89% · Performance 24.08% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 9.01% · Performance 9.30% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.14
Baseline 58.57% · Performance 46.75% · Measure score 4.14 · Achievement 4.14 · Improvement 3
Adjusted total nurse staffing
0
Baseline 2.27 hours · Performance 2.40 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.73% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 163 · Observed rate 9.82% · Lower 95% interval 7.25% |
| Discharge to community | 43.94% |
50.57%
6.6 pts worse
|
No Different than the National Rate · Eligible stays 142 · Observed rate 36.62% · Lower 95% interval 38.1% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.35% |
95.27%
3.1 pts better
|
Numerator 119 · Denominator 121 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 121 |
| Discharge self-care score | 9.86% |
53.69%
43.8 pts worse
|
Numerator 7 · Denominator 71 |
| Discharge mobility score | 15.49% |
50.94%
35.4 pts worse
|
Numerator 11 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 4.96% |
2.29%
2.7 pts worse
|
Numerator 6 · Denominator 121 · Adjusted rate 4.98% |
| Healthcare-associated infections requiring hospitalization | 9.3% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 13.54% · Lower 95% interval 6.16% |
| Staff COVID-19 vaccination coverage | 11.11% |
8.2%
2.9 pts better
|
Numerator 12 · Denominator 108 |
| Staff flu vaccination coverage | 9.82% |
42%
32.2 pts worse
|
Numerator 11 · Denominator 112 |
| Discharge function score | 8.45% |
56.45%
48 pts worse
|
Numerator 6 · Denominator 71 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 48 · Denominator 48 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 22.58% |
25.2%
2.6 pts worse
|
Numerator 14 · Denominator 62 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.0
0.2 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.3
0.3 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.4% |
89.6%
12.2 pts worse
|
93.4%
16 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.0% · Q2 76.3% · Q3 78.0% · Q4 76.2% · 4Q avg 77.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.5% |
91.6%
1.1 pts worse
|
95.5%
5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.3%
0.2 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.6% · Q3 4.9% · Q4 1.2% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 99.3% |
50.3%
49 pts worse
|
11.4%
87.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 100.0% · Q4 98.6% · 4Q avg 99.3% |
| Percentage of long-stay residents who lose too much weight | 14.2% |
6.5%
7.7 pts worse
|
5.4%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 19.4% · Q3 15.7% · Q4 11.8% · 4Q avg 14.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.9% |
18.5%
4.4 pts worse
|
19.6%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 20.6% · Q3 24.3% · Q4 24.7% · 4Q avg 22.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.2% |
22.8%
2.6 pts better
|
16.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 25.9% · Q3 14.9% · Q4 20.0% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.3% |
17.2%
10.9 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 3.7% · Q3 2.7% · Q4 4.4% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.9% |
15.0%
11.1 pts better
|
14.9%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 7.4% · Q3 0.0% · Q4 5.5% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.8% |
21.3%
1.5 pts worse
|
19.8%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 16.6% · Q3 33.3% · Q4 19.6% · 4Q avg 22.8% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.2%
0.7 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.0% · Q3 5.0% · Q4 1.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.4% |
68.8%
16.4 pts worse
|
81.7%
29.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 46.6% · Q2 53.2% · Q3 52.0% · Q4 58.0% · 4Q avg 52.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.3% |
14.0%
2.3 pts worse
|
12.0%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 17.5% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.3%
0.7 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 3.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.2% |
63.0%
6.8 pts worse
|
79.7%
23.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 36.1% |
26.2%
9.9 pts worse
|
23.9%
12.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 36.1% · Observed 40.2% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-03 · Fire 2023-11-03
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-12-22 · Fire 2022-12-22
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-27
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-27
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-27
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-10-10
E · Potential for more than minimal harm
2024-09-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-10
F · Potential for more than minimal harm
2023-11-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-06
F · Potential for more than minimal harm
2023-11-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-06
E · Potential for more than minimal harm
2023-11-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-12-06
F · Potential for more than minimal harm
2022-12-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-12-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-18
F · Potential for more than minimal harm
2022-12-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-12-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-12-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-01-18
E · Potential for more than minimal harm
2022-12-22
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-01-18
C · Minimal harm
2022-12-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-18
Inspection history
Recent health citations
G · Actual harm
2025-10-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-10-20
F · Potential for more than minimal harm
2024-09-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-07
E · Potential for more than minimal harm
2024-09-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-27
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-09-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-04
C · Minimal harm
2024-09-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-04
G · Actual harm
2023-12-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-03
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-11-03
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-11-03
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-11-09
D · Potential for more than minimal harm
2023-04-20
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-02
F · Potential for more than minimal harm
2022-12-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-12-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-12-22
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2023-01-06
E · Potential for more than minimal harm
2022-12-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-06
D · Potential for more than minimal harm
2022-12-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-01-06
Penalties and ownership
What sits behind the stars
Ownership
Aaron, Jonathan
5% Or Greater Direct Ownership Interest · Individual
Todd A Stern 2015 Irrv Ins Tr
5% Or Greater Direct Ownership Interest · Organization
Ab Investment Trust U/A/D 01/03/23
5% Or Greater Direct Ownership Interest · Organization
Israel Family Investment Trust
5% Or Greater Direct Ownership Interest · Organization
Israel Investment Tr
5% Or Greater Direct Ownership Interest · Organization
Aaron, Jonathan
Operational/Managerial Control · Individual
Aaron, Jonathan
Corporate Officer · Individual
Gifford, Robin
Operational/Managerial Control · Individual
Graf, Marcella
Operational/Managerial Control · Individual
Robin, Jason
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Miller Health Care Center
Kankakee, IL
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Arc at Kankakee
Kankakee, IL
3-star overall rating with 3-star inspections with $86,813 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Citadel Care Center-Kankakee
Kankakee, IL
2-star overall rating with 4-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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