Citadel of Bourbonnais: Resident Falls, Gets 12 Stitches - IL
The October 2025 complaint inspection cited the facility for actual harm under F0689, the federal tag covering accident prevention. The violation affected a small number of residents.
The resident, identified in inspection records as R1, had a care plan that called for two quarter side rails to help him turn and reposition himself in bed. The rails were meant to give him something to hold onto, to keep him stable during movement. They were not in use when he needed them.
He fell out of bed. The laceration on his forehead required 12 stitches to close.
A family member, identified in the report as V5, spoke with inspectors after the incident. She said she believes the rails would have prevented it. "If the plan of care to have the two quarter side rails was implemented, it could have potentially prevented R1 from rolling out of bed and sustaining lacerations on his forehead," she told investigators.
V5 said she expects staff to provide all necessary safety measures to make sure a resident does not roll out of bed during care. That expectation is not complicated. It is the basic transaction of a nursing home: a family places someone in a facility's hands, and the facility follows the plan designed to keep that person safe.
The fall was not the only serious concern surrounding R1 in the days before and after.
The inspection report notes that R1 was taken to the emergency department on October 3, 2025. V5 told inspectors there was no psychiatric evaluation performed at the hospital during that visit, which she described as routine for emergency department admissions. She said the absence of such an evaluation led her to believe the emergency department did not consider a reported suicidal attempt credible. R1 himself denied any suicidal attempt or ideation after returning to the facility.
V5 was direct with inspectors about what she believes. Residents at the facility should be safe during the provision of care by staff. That is what she said. The record from this inspection suggests that, on at least one occasion, R1 was not.
The inspection was triggered by a complaint, not a routine survey. That distinction matters. Complaint inspections happen because someone reached out, gave a name or a description, and said something had gone wrong. In this case, someone did.
The Citadel of Bourbonnais is a long-term care facility in Kankakee County, south of Chicago. The October 7 inspection resulted in a finding of actual harm, the federal designation used when inspectors conclude that a violation caused real injury to a resident, not merely the risk of one. R1's forehead, and the 12 stitches required to close it, is what actual harm looks like in a CMS inspection report.
The care plan existed. The quarter side rails were listed. The staff did not use them. A man who needed help staying in bed during repositioning rolled onto the floor and bled.
V5 told inspectors she remained a resident at the facility after the fall incident, which in context suggests she was describing R1's continued presence there, not her own. She had spoken to hospital staff. She had spoken to inspectors. She was trying to understand how something written into her family member's care plan had simply not happened.
She did not get a clear answer in the pages of this inspection report. What she got was a citation, a finding of actual harm, and a three-page document that ends with her belief that a simple piece of equipment, two quarter rails on a bed, could have kept him from hitting the floor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Citadel of Bourbonnais,the from 2025-10-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 11, 2026 · Our methodology
CITADEL OF BOURBONNAIS,THE in BOURBONNAIS, IL was cited for violations during a health inspection on October 7, 2025.
The October 2025 complaint inspection cited the facility for actual harm under F0689, the federal tag covering accident prevention.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.