Citadel Of Bourbonnais,the

Penalties

• Oct 7, 2025 — IDPH fine (Nursing Home Care Act) ($2,200)

Inspection findings

1. Oct 7, 2025 Health · 2 findings
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Oct 20, 2025 · CMS health inspection

   • Not serious Scope/severity B

     Type B Illinois Nursing Home Care Act violation

     Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.1210b)4)5), 300.1210c), and 300.1210d)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation:300.1210b) and 300.1210d)6).

     Statement of deficiencies (PDF)

2. Sep 27, 2024 Health · 16 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Oct 4, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Oct 4, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Oct 4, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0688 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.

     Corrected Oct 4, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Oct 7, 2024 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Oct 4, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Oct 7, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Oct 4, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0222 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.

     Corrected Oct 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0281 Egress Deficiencies

     Install proper backup exit lighting.

     Corrected Oct 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Oct 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Oct 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Oct 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Oct 10, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Oct 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Oct 10, 2024 · CMS fire safety

3. Dec 29, 2023 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 15, 2024 · CMS health inspection

4. Nov 3, 2023 Health · 8 findings
   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Nov 9, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0688 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.

     Corrected Nov 9, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0813 Nutrition and Dietary Deficiencies

     Have a policy regarding use and storage of foods brought to residents by family and other visitors.

     Corrected Nov 9, 2023 · CMS health inspection

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Dec 6, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Dec 6, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Dec 6, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Dec 6, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Dec 6, 2023 · CMS fire safety

5. Dec 22, 2022 Health · 15 findings
   • Not serious Scope/severity E

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Jan 6, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jan 6, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0690 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.

     Corrected Jan 6, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Jan 6, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jan 6, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0803 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.

     Corrected Jan 6, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jan 6, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 6, 2023 · CMS health inspection

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jan 18, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 18, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jan 18, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Jan 18, 2023 · CMS fire safety

   • Not serious Scope/severity C

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jan 18, 2023 · CMS fire safety

   • Not serious Scope/severity E

     K0781 Miscellaneous Deficiencies

     Have restrictions on the use of portable space heaters.

     Corrected Jan 18, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jan 18, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• AARON, JONATHAN — corporate officer, NOT APPLICABLE, since 11/01/2020
• AARON, JONATHAN — adp of the snf, NOT APPLICABLE, since 11/01/2020
• AARON, JONATHAN — operational/managerial control, NOT APPLICABLE, since 11/01/2020
• BERGER, MENACHEM — trustee of the snf, NOT APPLICABLE, since 11/01/2020
• BERGER, MENACHEM — direct ownership interest, NOT APPLICABLE, since 04/01/2023
• BERGER, MENACHEM — adp of the snf, NOT APPLICABLE, since 11/01/2020
• GIFFORD, ROBIN — operational/managerial control, NOT APPLICABLE, since 08/04/2022
• GIFFORD, ROBIN — adp of the snf, NOT APPLICABLE, since 08/04/2022
• GRAF, MARCELLA — direct ownership interest, NOT APPLICABLE, since 11/01/2020
• GRAF, MARCELLA — adp of the snf, NOT APPLICABLE, since 11/01/2020
• GRAF, MARCELLA — operational/managerial control, NOT APPLICABLE, since 11/01/2020
• GROSS, SHOSHANA — adp of the snf, NOT APPLICABLE, since 04/01/2023
• GROSS, SHOSHANA — direct ownership interest, NOT APPLICABLE, since 04/01/2023
• PROCTOR, KATHERINE — adp of the snf, NOT APPLICABLE, since 04/01/2023
• PROCTOR, KATHERINE — direct ownership interest, NOT APPLICABLE, since 04/01/2023
• ROBIN, JASON — adp of the snf, NOT APPLICABLE, since 05/01/2024
• ROBIN, JASON — operational/managerial control, NOT APPLICABLE, since 05/01/2024
• TELLER, CHANANEL — adp of the snf, NOT APPLICABLE, since 04/01/2023
• TELLER, CHANANEL — direct ownership interest, NOT APPLICABLE, since 04/01/2023
• 20 BRIARCLIFF LANE LLC — adp of the snf, NOT APPLICABLE, since 02/17/2025
• AB INVESTMENT TRUST U/A/D 01/03/23 — adp of the snf, NOT APPLICABLE, since 11/01/2020
• AB INVESTMENT TRUST U/A/D 01/03/23 — 5% or greater direct ownership interest, 10%, since 11/01/2020
• ISRAEL FAMILY INVESTMENT TRUST — adp of the snf, NOT APPLICABLE, since 11/01/2020
• ISRAEL INVESTMENT TR — adp of the snf, NOT APPLICABLE, since 11/01/2020
• OMNIA HEALTHCARE GROUP LLC — adp of the snf, NOT APPLICABLE, since 01/01/2024
• TODD A STERN 2015 IRRV INS TR — adp of the snf, NOT APPLICABLE, since 11/01/2020