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River Bluff Nursing Home

4401 North Main Street, Rockford, IL 61103 · Winnebago County · (815) 921-9200

304 certified beds, about 152 residents a day · Government - County · Medicare and Medicaid since 1993

Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
4 of 5
Quality measures
2 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 145771 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on June 24, 2026, inspectors cited 12 health deficiencies (the Illinois average is 12.6, the national average 9.2).

Of 38 health citations since October 2023, 6 were rated as actual harm or immediate jeopardy to residents.

CMS lists 2 fines totaling $48,629 in the last three years; the largest was $38,430, and the latest is dated June 24, 2026.

Nurses and nurse aides worked 4.19 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 0.80 of those hours.

44.4% of nursing staff left within the year CMS measured (Illinois average 44.5%).

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 38 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
6G
0H
0I
Potential for more than minimal harm
28D
3E
1F
Potential for minimal harm
0A
0B
0C
June 24, 2026Standard inspection, Complaint inspection · 12 citations
  1. G
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor a resident after a significant weight loss and failed to ensure a resident's nutritional supplements were implemented after a significant weight loss. This failure resulted in the residents having continued weight loss. This applies to 2 residents (R77, R67) reviewed for weight loss in a sample of 36.
  2. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure clean kitchen pans and boiling water used for cooking were maintained in a manner to prevent contamination and failed to ensure frozen food items were labeled and dated. This applies to all 150 residents residing in the facility.
  3. E
    Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
    F805 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pureed food was of a smooth consistency was served for 4 of 4 residents (R70, R77, R110, R125) reviewed for pureed food in the sample of 36.
  4. D
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on observation, interview and record review the facility failed to provide a wider bed for a resident upon request. This applies to 1 of 36 residents (R78) reviewed for accommodation of needs in the sample of 36.
  5. D
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    F605 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on interview and record review the facility failed to ensure PRN (when needed) psychotropic medications had stop dates. This applies to 3 of 6 residents (R12, R13 & R113) reviewed for unnecessary medications in the sample of 36.
  6. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on observation, interview and record review the facility failed to treat a resident experiencing a change of condition in a timely manner. The facility also failed to ensure resident's ace wraps were applied to their legs as ordered. This applies to 3 of 36 residents (R2, R23, R95) reviewed for quality of care in the sample of 36.
  7. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate assessment, treatment and care planning for a newly acquired pressure injury and failed to implement interventions to promote healing and prevent worsening of wounds for 2 of 7 residents (R7 and R82) reviewed for pressure in the sample of 36.
  8. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a residents indwelling drainage bag was positioned below the level of the bladder to prevent the backflow of urine. This applies to 1 of 6 residents (R23) reviewed for catheters in the sample of 36.
  9. D
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    F744 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff knew how to appropriately respond, assess and address behaviors for residents exhibiting behavioral symptoms with a diagnoses of dementia. This applies to 3 of 6 residents (R72, R75 & R113) reviewed for dementia care in the sample of 36.
  10. D
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered. There were 40 opportunities with 2 errors resulting in a 5% error rate. This applies to 2 of 6 residents (R113 & R120) observed in the medication pass.
  11. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure medication was labeled with an open date, discarded once expired and failed to verify a resident's home medications prior to use. This applies to 3 of 6 residents (R10, R113 & R131) reviewed for medication storage in the sample of 36.
  12. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 10, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff followed infection prevention and control practices, including the use of personal protective equipment and hand hygiene, to prevent cross contamination for 1 of 36 residents (R6) reviewed for infection control in the sample of 36.
May 26, 2026Complaint inspection · 1 citation
  1. D
    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.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 1, 2026
    Inspectors wroteBased on interview and record review the facility failed to ensure a resident was offered a maintenance ambulation plan for 1 of 3 residents (R2) reviewed for maintaining mobility in the sample of 3.
May 13, 2026Complaint inspection · 1 citation
  1. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 22, 2026
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were given as ordered for 1 of 3 residents (R2) reviewed for medication administration in the sample of 3.
April 22, 2026Complaint inspection · 1 citation
  1. D
    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.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 4, 2026
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure a residents restorative walking program was followed. This applies to 1 of 3 residents (R1) reviewed for restorative services in the sample of 5.
February 5, 2026Complaint inspection · 3 citations
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 20, 2026
    Inspectors wroteBased on interview and record review the facility failed to care for and transfer a resident in a safe manner to prevent a resident injury for 1 of 3 residents (R1) reviewed for resident safety and supervision in the sample of 3. This failure resulted in R1 falling while being cared for by facility staff. R1 was hospitalized due to the fall where he was diagnosed with an unstable vertebral (spine) fracture.
  2. G
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 20, 2026
    Inspectors wroteBased on interview and record review the facility failed to effectively manage and treat a resident's pain after the resident fell in the facility. The facility failed to notify the attending physician/nurse practitioner of this resident's worsening pain. These failures apply to 1 of 3 residents (R1) reviewed for pain management in the sample of 3. These failures resulted in R1 experiencing worsening, severe lower back pain caused by a thoracic vertebral (spine) fracture he sustained when he fell in the facility.
  3. D
    Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
    F776 · Administration · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) February 20, 2026
    Inspectors wroteBased on interview and record review the facility failed to ensure a resident's radiology studies (X-ray) were completed as ordered for 1 of 1 residents (R1) reviewed for radiology and diagnostic services in the sample of 3.
July 17, 2025Complaint inspection · 1 citation
  1. D
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    F925 · Environmental · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 29, 2025
    Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure for bed bug prevention and management. This failure resulted in bed bugs being found in R2 and R3's shared room. This failure applies to 2 of 3 residents (R2 & R3) reviewed for bed bugs in the sample of 4.1. The Progress Notes dated 7/4/2 for R2 did not show any documentation regarding bed bugs being found in his room, and care and/or procedures done related to the bed bugs. On 7/15/25 at 9:02 AM, V1 Administrator stated if the facility suspects or see any bed bugs, they try to capture the bug for the exterminator. The exterminator is called. The room is checked. The resident is removed from the room. Everything is bagged and the room is taped off. The bathroom is taped off from the inside if it's connected to an adjacent room. V1 stated maintenance calls the exterminator; [...]
April 10, 2025Standard inspection · 7 citations
  1. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 25, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely incontinence care for one of one residents (R83) reviewed for activities of daily living in the sample of 43.
  2. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 25, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician ordered pressure ulcer dressing/treatment was in place for one of seven residents (R21) reviewed for pressure ulcers in the sample of 43.
  3. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 25, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall interventions were in place. This failure applies to three of seven residents (R95, R38, R84) reviewed for falls in the sample of 43.
  4. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 25, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's indwelling catheter was below the level of the resident's bladder. This applies to one of two residents (R127) reviewed for indwelling urinary catheters in the sample of 43.
  5. D
    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.
    F693 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 25, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to verify tube placement of a gastric tube using an approved method prior to giving medications and a bolus feeding. This applies to one of one resident (R62) in the sample of 43 reviewed for feeding tubes.
  6. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 25, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure physician prescribed medications were administered as ordered for two of two residents (R30, R62) reviewed for medication administration in the sample of 43.
  7. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 25, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) while providing incontinent care and doing a dressing change for one of six residents (R21) reviewed for infection control in the sample of 43.
December 23, 2024Complaint inspection · 1 citation
  1. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 9, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from physical abuse for 1 of 4 residents (R3) reviewed for abuse in the sample of 5.
November 13, 2024Complaint inspection · 1 citation
  1. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 6, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of resident-to-resident abuse were immediately reported for 2 of 5 residents (R2, R3) reviewed for abuse in the sample of 5.
June 20, 2024Complaint inspection · 1 citation
  1. D
    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.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 2, 2024
    Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received a written grievance decision for one of three residents (R1) reviewed for grievances in the sample of 7.
May 14, 2024Complaint inspection · 2 citations
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on interview and record review the facility failed to ensure fall prevention interventions were in place for a resident with a history of falls. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. This failure resulted in R1 falling and fracturing her left hip.
  2. D
    Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
    F776 · Administration · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 31, 2024
    Inspectors wroteBased on interview and record review the facility failed to provide timely radiology services for a resident who fell and was experiencing pain to her hip. This applies to 1 of 3 residents reviewed for falls/radiology services in the sample of 3.
March 7, 2024Standard inspection, Complaint inspection · 6 citations
  1. G
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) March 29, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to identify a pressure injury prior to becoming a deep tissue injury, failed to obtain treatment orders for a new pressure injury, and failed to implement pressure relieving interventions for a resident with multiple pressure injuries for 1 of 7 residents (R117) reviewed for pressure injury in the sample of 31. These failures resulted in R117 suffering a deep tissue injury to the right heel, a Stage 2 pressure injury to the right buttock, and a Stage 1 to the left lateral ankle.
  2. G
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) March 29, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to identify decreased food intake for residents and implement interventions to prevent a significant weight loss for 2 of 6 residents (R50 & R87) reviewed for nutrition in the sample of 31. These failures resulted in a 5% weight loss in one month for R50 and R87.
  3. E
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) April 26, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to supervise a resident with behaviors (R131) and failed to supervise a resident during meals (R24) for 2 of 9 residents reviewed for safety in the sample of 31.
  4. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 29, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to properly label an opened vial of Tuberculin solution (31 residents residing on Cardinal Unit) and an insulin pen (R93) reviewed during the medication storage and labeling task.
  5. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 29, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's oxygen tank was not empty and failed to ensure a resident's nebulizer mask was changed as ordered for 1 of 1 resident (R7) reviewed for respiratory care in the sample of 31.
  6. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 29, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care in a manner to prevent cross contamination, failed to ensure a CNA removed contaminated gloves and appropriately performed hand hygiene after providing incontinent care for two of four (R103, R111) residents reviewed for infection control in a sample of 31.
October 16, 2023Complaint inspection · 1 citation
  1. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 6, 2023
    Inspectors wroteBased on observation, interview, and record review, the facility failed to administer pressure ulcer treatment as ordered for 1 of 3 residents (R2) reviewed for pressure ulcers in the sample of 4.

Fire safety inspections

14 fire safety citations on file: 6 on June 24, 2026, 6 on April 10, 2025, 2 on March 7, 2024.

Every fire safety citation14 citations
  1. F
    Install a two-hour-resistant firewall separation.
    K 133 · June 24, 2026 · Corrected (the home has a date of correction)
  2. F
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · June 24, 2026 · Corrected (the home has a date of correction)
  3. F
    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
    K 521 · June 24, 2026 · Corrected (the home has a date of correction)
  4. F
    Provide properly sized and located linen or trash receptacles.
    K 754 · June 24, 2026 · Corrected (the home has a date of correction)
  5. E
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · June 24, 2026 · Corrected (the home has a date of correction)
  6. E
    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.
    K 222 · June 24, 2026 · Corrected (the home has a date of correction)
  7. F
    Provide primary/alternate means for communication.
    E 32 · April 10, 2025 · Corrected (the home has a date of correction)
  8. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · April 10, 2025 · Corrected (the home has a date of correction)
  9. F
    Have proper power supply for life support equipment.
    K 915 · April 10, 2025 · Corrected (the home has a date of correction)
  10. E
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · April 10, 2025 · Corrected (the home has a date of correction)
  11. E
    Have an enclosure around a vertical opening shaft.
    K 311 · April 10, 2025 · Corrected (the home has a date of correction)
  12. E
    Ensure proper usage of power strips and extension cords.
    K 920 · April 10, 2025 · Corrected (the home has a date of correction)
  13. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · March 7, 2024 · Corrected (the home has a date of correction)
  14. E
    Install proper backup exit lighting.
    K 281 · March 7, 2024 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
June 24, 2026Fine $38,430
May 14, 2024Fine $10,199
March 7, 2024Payment Denial 21 days from April 5, 2024

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeIllinoisUnited States
All nursing staff (RN, LPN and aides)4.193.453.86
Registered nurses0.800.720.69
All nursing staff on weekends3.863.073.42
Nurse aides2.52
Licensed practical nurses0.87
Nursing staff turnover (share who left in a year)44.4%44.5%45.8%
Registered nurse turnover29.2%41.8%42.9%
Administrators who left0

CMS expects 4.14 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.32 on weekdays and 3.86 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 2.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.60 in April to June 2025 to 4.19 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20264.190.804.323.86 2.0%0 of 90152
Oct to Dec 20254.350.814.494.01 1.1%0 of 92152
Jul to Sep 20254.520.814.664.17 2.9%0 of 92151
Apr to Jun 20254.600.794.744.26 5.6%0 of 91145
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Illinois, Jan to Mar 20263.260.653.402.925.4%0.6% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeIllinoisUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
20.513.413.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.70.90.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
6.41.51.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
2.43.13.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
1.42.21.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
14.214.314.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
3.64.84.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
28.021.715.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
20.226.123.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
7.713.812.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.92.01.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.92.21.8

Owners and operators

Legal business name: COUNTY OF WINNEBAGO.

NameRoleTypeShareSince
Lofgren, MarkW-2 managing employeeIndividual06/10/2020
Lofgren, MarkCorporate directorIndividual06/10/2020
McDiarmid, PatriciaCorporate directorIndividual04/01/2019
County of WinnebagoOperational/managerial controlOrganization11/01/2008

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 20 problems in this area, most recently on June 24, 2026: "Provide enough food/fluids to maintain a resident's health."
  2. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 5 problems in this area, most recently on June 24, 2026: "Ensure medication error rates are not 5 percent or greater."
  3. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 3 problems in this area, most recently on June 24, 2026: "Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function."
  4. What changed in infection control since the last inspection, and who on staff is the infection preventionist?Inspectors cited 3 problems in this area, most recently on June 24, 2026: "Provide and implement an infection prevention and control program."

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Common questions

What is River Bluff Nursing Home's Medicare star rating?
CMS rates River Bluff Nursing Home 2 out of 5 stars overall, with 2 for health inspections, 4 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did River Bluff Nursing Home get at its last inspection?
12 health deficiencies at the standard inspection on June 24, 2026. The Illinois average is 12.6.
Has River Bluff Nursing Home been fined?
Yes. CMS lists 2 fines totaling $48,629 in the last three years.
Does River Bluff Nursing Home accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns River Bluff Nursing Home?
CMS lists 4 owners and managers. Legal business name: COUNTY OF WINNEBAGO.

Sources

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