Citadel Of Bourbonnais,the
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
resident at the facility after the fall incident, and he denied suicidal attempt/ideation. V5 further stated that there was no psychiatric evaluation done at the hospital on October 3, 2025, which is a routine evaluation at the emergency department. This led her (V5) to believe that the emergency department does not believe
the suicidal attempt was true. During the same interview, V5 stated that residents at the facility should be safe during the provision of their care by the staff. V5 stated that she expects the staff to provide all necessary safety measures to ensure that resident does not roll out of bed and sustain injury during provision of care. According to V5, the facility should implement their own plan of care for Resident R1, including providing the two quarter side rails for turning and/or repositioning the resident to aide in bed mobility.
Additionally, V5 stated that if the plan of care to have the two quarter side rails was implemented, it could have potentially prevented Resident R1 from rolling out of bed and sustaining lacerations on his forehead requiring 12 stitches.
Event ID:
Facility ID:
If continuation sheet
CITADEL OF BOURBONNAIS,THE in BOURBONNAIS, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in BOURBONNAIS, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CITADEL OF BOURBONNAIS,THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.