Citadel of Bourbonnais,the

Name: Citadel of Bourbonnais,the
Address: 20 BRIARCLIFF LANE, Bourbonnais, IL, 60914, US
Telephone: 8159372022

20 Briarcliff Lane, Bourbonnais, IL 60914 · Kankakee County · 107 certified beds · avg 90 residents/day · certified since Jan 29, 1986

Part of chain: CITADEL HEALTHCARE (14 facilities, chain avg rating 3.2★)

4/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

2.68

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★☆4/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Oct 7, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Oct 20, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Dec 29, 2023 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Jan 15, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (21)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Oct 7, 2025	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Sep 27, 2024	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Sep 27, 2024	E · Potential for harm, repeated	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Sep 27, 2024	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Sep 27, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Sep 27, 2024	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Sep 27, 2024	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Sep 27, 2024	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Sep 27, 2024	C · Minimal risk, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Dec 29, 2023	▲ G · Actual harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Nov 3, 2023	D · Potential for harm, one-off	The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate.
Nov 3, 2023	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Nov 3, 2023	D · Potential for harm, one-off	The facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
Dec 22, 2022	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Dec 22, 2022	E · Potential for harm, repeated	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Dec 22, 2022	E · Potential for harm, repeated	The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician.
Dec 22, 2022	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Dec 22, 2022	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Dec 22, 2022	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Dec 22, 2022	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Dec 22, 2022	D · Potential for harm, one-off	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (3 → 8).

Year	Citations	Serious (G–L)	Worst severity that year
2022	8	0	F
2023	4	1	G ▲
2024	8	0	F
2025	1	1	G ▲

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Illinois avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	2.68	2.99	3.95	top 49% in Illinois; bottom 6% in the U.S.
Registered Nurse hours	0.49	0.63	0.69	bottom 49% in Illinois; bottom 36% in the U.S.
Weekend total nurse staffing	2.34	2.67	3.50	bottom 45% in Illinois; bottom 6% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.48	0.56	0.48	top 46% in Illinois; top 35% in the U.S.
Total nursing staff turnover (%)	58.1	44.5	45.8	bottom 17% in Illinois; bottom 19% in the U.S.
RN turnover (%)	50.0	41.8	42.9	bottom 37% in Illinois; bottom 39% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.46, RN 0.63, weekend 3.02. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 2/5 · long-stay residents: 5/5 · short-stay residents: 1/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Ab Investment Trust U/A/D 01/03/23	Organization	5% or Greater Direct Ownership Interest	10%	11/01/2020
Berger, Menachem	Individual	Direct Ownership Interest	NOT APPLICABLE	04/01/2023
Graf, Marcella	Individual	Direct Ownership Interest	NOT APPLICABLE	11/01/2020
Gross, Shoshana	Individual	Direct Ownership Interest	NOT APPLICABLE	04/01/2023
Proctor, Katherine	Individual	Direct Ownership Interest	NOT APPLICABLE	04/01/2023
Teller, Chananel	Individual	Direct Ownership Interest	NOT APPLICABLE	04/01/2023
20 Briarcliff Lane LLC	Organization	ADP of the SNF	NOT APPLICABLE	02/17/2025
Aaron, Jonathan	Individual	Corporate Officer	NOT APPLICABLE	11/01/2020
Aaron, Jonathan	Individual	Operational/Managerial Control	NOT APPLICABLE	11/01/2020
Aaron, Jonathan	Individual	ADP of the SNF	NOT APPLICABLE	11/01/2020
Ab Investment Trust U/A/D 01/03/23	Organization	ADP of the SNF	NOT APPLICABLE	11/01/2020
Berger, Menachem	Individual	Trustee of the SNF	NOT APPLICABLE	11/01/2020
Berger, Menachem	Individual	ADP of the SNF	NOT APPLICABLE	11/01/2020
Gifford, Robin	Individual	Operational/Managerial Control	NOT APPLICABLE	08/04/2022
Gifford, Robin	Individual	ADP of the SNF	NOT APPLICABLE	08/04/2022
Graf, Marcella	Individual	Operational/Managerial Control	NOT APPLICABLE	11/01/2020
Graf, Marcella	Individual	ADP of the SNF	NOT APPLICABLE	11/01/2020
Gross, Shoshana	Individual	ADP of the SNF	NOT APPLICABLE	04/01/2023
Israel Family Investment Trust	Organization	ADP of the SNF	NOT APPLICABLE	11/01/2020
Israel Investment Tr	Organization	ADP of the SNF	NOT APPLICABLE	11/01/2020

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
"How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Miller Health Care Center	2.1 mi	Kankakee, IL	★★☆☆☆	2/5
Arc at Kankakee	2.1 mi	Kankakee, IL	★★★☆☆	3/5
Citadel Care Center-Kankakee	2.2 mi	Kankakee, IL	★★★★☆	4/5
Arc at Bradley	2.3 mi	Bradley, IL	★☆☆☆☆	2/5
Momence Meadows Nursing & Rehab	12.2 mi	Momence, IL	★☆☆☆☆	2/5	abuse
La Bella at Clifton	15.4 mi	Clifton, IL	★☆☆☆☆	2/5
Aperion Care Wilmington	16.1 mi	Wilmington, IL	★☆☆☆☆	1/5	abuse
Beecher Manor Nrsg & Rehab Ctr	19.9 mi	Beecher, IL	★★☆☆☆	3/5

Compare this facility with the 3 closest →

All facilities in Bourbonnais →

Facility data as of CMS processing date 2026-08-01. CCN 145536.

The Care File

Visit checklist — Citadel of Bourbonnais,the

20 Briarcliff Lane, Bourbonnais, IL 60914 · 8159372022

Health inspection rating 4/5 · CMS overall 3/5· Fines (3y): $0

Most serious findings on record:

▲ Oct 7, 2025 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ Dec 29, 2023 (F-0689, Actual harm, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "What do you do daily to keep residents moving, and how do you help residents at risk of losing mobility?"
☐ "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 145536 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)