River Bluff Nursing Home
4401 North Main Street, Rockford, IL 61103
River Bluff Nursing Home is a nursing home in Rockford, Illinois. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 1 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 1 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (815) 921-9200
- Last standard health inspection
- June 24, 2026 (4 months ago)
- Certified beds
- 304
- Residents per day, on average
- 148.2
- Ownership type
- Government - County
- Legal business name
- County of Winnebago
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
The same number of health citations as the Illinois average (38).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
CMS update of July 29, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 1 of 5 to 2 of 5.
12 citations
Health inspection on June 24, 2026
CMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
285 of 664 Illinois homes (43%) got a citation at the actual harm level in 2026.
Citation F0692. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for F0692 2 times since 2024.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 10, 2026.
Citation F0805. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on July 10, 2026.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on July 10, 2026.
Citation F0605. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
CMS lists it as corrected on July 10, 2026.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 10, 2026.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for F0686 4 times since 2023.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for F0690 2 times since 2025.
Citation F0744. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
CMS lists it as corrected on July 10, 2026.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on July 10, 2026.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for F0761 2 times since 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 10, 2026.
CMS has cited this home for F0880 3 times since 2024.
6 citations
Fire safety inspection on June 24, 2026
CMS lists this as a standard inspection.
Citation K0133. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install a two-hour-resistant firewall separation.
CMS lists it as corrected on July 7, 2026.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on July 7, 2026.
Citation K0521. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on July 7, 2026.
Citation K0754. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide properly sized and located linen or trash receptacles.
CMS lists it as corrected on July 7, 2026.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on July 7, 2026.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 1, 2026.
Fine
June 24, 2026 (4 months ago)
CMS fine of $38,430 on June 24, 2026.
1 citation
Health inspection on May 26, 2026
CMS lists this as a complaint inspection.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 1, 2026.
CMS has cited this home for F0688 2 times since 2026.
1 citation
Health inspection on May 13, 2026
CMS lists this as a complaint inspection.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 22, 2026.
CMS has cited this home for F0755 2 times since 2025.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 3 of 5.
1 citation
Health inspection on April 22, 2026
CMS lists this as a complaint inspection.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on May 4, 2026.
3 citations
Health inspection on February 5, 2026
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
285 of 664 Illinois homes (43%) got a citation at the actual harm level in 2026.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 20, 2026.
CMS has cited this home for F0689 4 times since 2024.
Citation F0697. Severity G: actual harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on February 20, 2026.
Citation F0776. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
CMS lists it as corrected on February 20, 2026.
CMS has cited this home for F0776 2 times since 2024.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.
Health citation
CMS removed citation F0689 from the health inspection on May 14, 2024.
Health citation
CMS removed citation F0776 from the health inspection on May 14, 2024.
1 citation
Health inspection on July 17, 2025
CMS lists this as a complaint inspection.
Citation F0925. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on July 29, 2025.
CMS update of May 28, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Fine
CMS changed the fine from May 14, 2024 from $10,033 to $10,199.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 1 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS quality measures star rating changed from 2 of 5 to 1 of 5.
7 citations
Health inspection on April 10, 2025
CMS lists this as a standard inspection.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on April 25, 2025.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on April 25, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 25, 2025.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on April 25, 2025.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS lists it as corrected on April 25, 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on April 25, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on April 25, 2025.
6 citations
Fire safety inspection on April 10, 2025
CMS lists this as a standard inspection.
Citation E0032. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide primary/alternate means for communication.
CMS lists it as corrected on May 15, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on May 15, 2025.
Citation K0915. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have proper power supply for life support equipment.
CMS lists it as corrected on June 9, 2025.
Citation K0223. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on May 15, 2025.
Citation K0311. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on May 15, 2025.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on May 15, 2025.
CMS update of March 26, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 3 of 5.
Fine
CMS changed the fine from May 14, 2024 from $15,435 to $10,033.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
1 citation
Health inspection on December 23, 2024
CMS lists this as a complaint inspection.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on January 9, 2025.
1 citation
Health inspection on November 13, 2024
CMS lists this as a complaint inspection.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on December 6, 2024.
CMS update of September 26, 2024
Fine
CMS changed the fine from September 26, 2022 from $18,827 to $19,251.
Fine
CMS changed the fine from November 22, 2022 from $33,660 to $35,657.
CMS update of August 29, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 3 of 5 to 2 of 5.
Fine
CMS changed the fine from May 18, 2022 from $16,452 to $16,911.
CMS update of July 31, 2024
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of June 26, 2024
Fine
CMS changed the fine from September 26, 2022 from $18,150 to $18,827.
1 citation
Health inspection on June 20, 2024
CMS lists this as a complaint inspection.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
CMS lists it as corrected on July 2, 2024.
CMS update of May 29, 2024
Fine
CMS changed the fine from May 18, 2022 from $15,000 to $16,452.
2 citations
Health inspection on May 14, 2024
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
383 of 664 Illinois homes (58%) got a citation at the actual harm level in 2024.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 31, 2024.
Citation F0776. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
CMS lists it as corrected on May 31, 2024.
Fine
May 14, 2024 (2 years ago)
CMS fine of $10,199 on May 14, 2024.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 4 of 5.
Payment stopped
April 5, 2024 (2 years ago)
CMS stopped payment for new admissions from April 5, 2024, for 21 days.
6 citations
Health inspection on March 7, 2024
CMS lists this as a standard inspection and a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
383 of 664 Illinois homes (58%) got a citation at the actual harm level in 2024.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on March 29, 2024.
Citation F0692. Severity G: actual harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on March 29, 2024.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 26, 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 29, 2024.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on March 29, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 29, 2024.
2 citations
Fire safety inspection on March 7, 2024
CMS lists this as a standard inspection.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 22, 2024.
Citation K0281. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install proper backup exit lighting.
CMS lists it as corrected on April 5, 2024.
CMS update of January 31, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
1 citation
Health inspection on October 16, 2023
CMS lists this as a complaint inspection.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on November 6, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- COUNTY OF WINNEBAGOOperational/managerial control · not applicable · since 11/01/2008
Questions
When was River Bluff Nursing Home last inspected?
CMS lists June 24, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does River Bluff Nursing Home have?
CMS lists 38 health citations since October 16, 2023. CMS also calls these deficiencies.
Has River Bluff Nursing Home been fined?
CMS lists 2 fines in the past three years, $48,629 in total.
What is the CMS star rating of River Bluff Nursing Home?
Its CMS overall star rating is 1 of 5.
Is River Bluff Nursing Home a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.