Citadel of Bourbonnais,The

In the surveyor’s words

From the most serious findings on record at Citadel of Bourbonnais,The, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 7, 2025

  Based 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.The findings include: R1 had multiple diagnoses including, atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified anxiety disorder and personal history of traumatic brain injury, based on the face sheet.R1's annual MDS (Minimum Data Set) dated September 30, 2025, showed R1… […]

• Actual harm, isolatedF689Dec 29, 2023

  Based 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. The findings include: R1's Face sheet shows diagnoses of diabetes with diabetic neuropathy, cerebral infarction, repeated falls, muscle weakness, and lack of coordination. R1's MDS (Minimum Data Set) dated 7/20/23 shows her cognition is intact. On 12/28/23 at 9:52 AM an observation was made of the main shower room where R1's fall occurred. There are 3 shower stalls on the right-side wall, and 1 shower stall on the left wall. […]

• Actual harm, isolatedF677May 9, 2022

  Based on observation, interview, and record review, the facility failed to ensure a resident's Activities of Daily Living (ADL) cares were provided in a timely manner. This failure resulted in R5 reporting anxiety, humiliation, experiencing foot and leg swelling, and pain. This applies to 1 out of 4 residents (R5) reviewed for ADLs in a sample of 4. The findings include: R5's Face Sheet showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's 4/25/22 MDS (Minimum Data Set) showed her cognition is intact. The same MDS showed R5 requires extensive assistance for transfers and toileting. On 5/5/22 at 11:15 AM, R5 was sitting on the side of her bed. Dark purple bruising measuring approximately two inches long was present on R5's right arm. […]

• No harm, potential for more than minimal, widespreadF812Sep 27, 2024

  Based 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. Findings include: On [DATE] at 03:14 PM, V20 (Culinary Director) confirmed all 90 residents residing in the facility receive meals form dietary services. 1. On [DATE] at 11:01 AM, one red sanitization bucket in use tested at 100 ppm (Parts Per Million). On [DATE] at 10:23 AM, V20 (Culinary Director) stated the quat sanitizer for the red sanitization bucket should test between 300 and 400 ppm. On [DATE] at 11:15 AM, V20 stated the red sanitization bucket use quat for sanitization concentration range should be between 150 to 400 ppm. […]

• No harm, potential for more than minimal, widespreadF812Dec 22, 2022

  Based 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. The findings include: Facility Resident Census and Conditions of Residents form (CMS Form 672) dated 12/19/22 showed that the census of the facility was 92. Facility provided documentation that there was only one resident on NPO (Nothing by mouth) status on 12/19/22. 1. On 12/19/22 at 09:44 AM, the initial tour of the facility kitchen was done in the presence of V11 (Culinary Director). […]