A list of the most recent deficiencies for Citadel of Bourbonnais,the. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-29 | 2024-01-15 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-11-07 | 2023-12-06 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-11-07 | 2023-12-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-07 | 2023-12-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-11-07 | 2023-12-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-11-07 | 2023-12-06 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-03 | 2023-11-09 | N |
| 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. | Health | 2023-11-03 | 2023-11-09 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-11-03 | 2023-11-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-20 | 2023-05-02 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-04 | 2023-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-04 | 2023-01-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-04 | 2023-01-18 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-01-04 | 2023-01-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-04 | 2023-01-18 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-01-04 | 2023-01-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-04 | 2023-01-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-22 | 2023-01-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-22 | 2023-01-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-12-22 | 2023-01-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-22 | 2023-01-06 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-12-22 | 2023-01-06 | N |
| 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. | Health | 2022-12-22 | 2023-01-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-22 | 2023-01-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-22 | 2023-01-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-04 | 2022-10-11 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-09 | 2022-05-25 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-09-09 | 2021-10-05 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-08-20 | 2021-09-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-20 | 2021-09-08 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-08-20 | 2021-09-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-20 | 2021-09-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-08-20 | 2021-09-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-20 | 2021-09-08 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-08-16 | 2021-08-23 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-13 | 2021-05-28 | Y |
