Citadel of Bourbonnais,the
Strong Medicare quality ratings; families often praise compassionate and attentive nursing staff. Still worth an in-person visit.
based on 78 Google reviews
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What this means for your family
While many families report excellent care and a clean environment, there are recurring, serious reports of medical neglect and communication failures. We strongly recommend that you visit frequently and maintain a proactive role in monitoring your loved one's medication and personal supplies to ensure their needs are consistently met.
Google Reviews
Google Reviews
78 reviews on Google“The Citadel of Bourbonnais receives highly polarized feedback, with many families praising the compassionate nursing staff and clean environment for long-term and rehab care. However, a significant number of reviewers report serious concerns regarding medical neglect, poor communication, and the loss of personal belongings. Families considering this facility should be aware of these inconsistencies in care quality and administrative responsiveness.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate and attentive nursing staff
- Clean and well-maintained facility
- Effective rehab therapy team
- Responsive customer service management
Concerns
- Poor communication and lack of responsiveness from staff (mentioned by 3 reviewers)
- Medical neglect, including missing medications and supplies (mentioned by 3 reviewers)
- Loss or theft of personal belongings (mentioned by 2 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 79 analyzed
How They Respond to Reviews
This facility actively engages with reviewer feedback.
Questions for Your Tour
- 1Given that staffing levels are a priority for us, could you walk me through how your team manages daily care assignments to ensure consistent attention for all 107 residents?
- 2I noticed that communication is a key focus for your management team; what specific protocols do you have in place to keep families updated on their loved one's daily health status and medication changes?
- 3How does your facility handle the security of personal belongings, and what steps do you take to prevent items from being misplaced?
- 4I see that you actively engage with feedback online; how does that process help you improve the quality of care or address specific family concerns in real-time?
- 5Could you describe the process for ensuring that medications are tracked and administered accurately, especially during shift changes?
- 6What does a typical day look like for residents here, and how do you encourage participation in activities to keep everyone socially and physically active?
Personalized based on this facility's data
Key Review Excerpts
“My grandpa has been a long term resident for over two years now. It took him some time to feel comfortable but now he feels like it’s home. He is a picky eater and they are really good at giving him snacks he will actually eat.”
“My mom came to Citadel after being at another facility and when she arrived she had bedsores that she endured from another facility Citadel wound care team and staff worked diligently to get her sores healed up.”
“Everyday it was a different excuse as to why my mother did not have her medical supplies such as C-Pap machine as well as pain medications for several illnesses including those that are terminal.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Total nursing hours are below minimum, though RN coverage is adequate. This may mean fewer aides for daily tasks like bathing and mobility.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
6
measures
7
measures
4
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose walking got worse
Residents vaccinated for pneumonia
Residents needing more daily help over time
Residents who lost too much weight
Residents on anti-anxiety or sleep medication
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility has a concerning pattern of repeat safety violations, with families filing formal complaints about accident hazards that have occurred multiple times across surveys. The most frequent issues involve fire safety systems, accident prevention, and nutrition services, with many of the same problems recurring despite reported corrections. While all deficiencies show correction dates, the persistence of similar violations suggests ongoing operational challenges that families should carefully consider.
Oct 7, 2025Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Sep 27, 2024Routine16
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Egress Deficiencies
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.
Egress Deficiencies
Install proper backup exit lighting.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Gas, Vacuum, and Electrical Systems Deficiencies
Meet requirements for the installation and maintenance of electrical systems.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
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.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Dec 29, 2023Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nov 3, 2023Routine8
Egress Deficiencies
Install emergency lighting that can last at least 1 1/2 hours.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Quality of Life and Care Deficiencies
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.
Nutrition and Dietary Deficiencies
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Dec 22, 2022Routine15
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Nutrition and Dietary Deficiencies
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.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Miscellaneous Deficiencies
Have restrictions on the use of portable space heaters.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Ownership & Operations
Who Operates This Facility
Citadel of Bourbonnais,the
for profit
Chain Affiliation
Citadel Healthcare
13 facilities nationwide
Chain avg rating: 3.1/5 · Rank 4 of 13
Ownership & Management
Owners
Ab Investment Trust U/a/d 01/03/23
Owner · Organization
Berger, Menachem
Owner
Graf, Marcella
Owner
Gross, Shoshana
Owner
Proctor, Katherine
Owner
Teller, Chananel
Owner
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
78 reviews from families & visitors
Official Website
Visit citadelofbourbonnais.com
Medicare data downloads
Original nursing home datasets
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