River Bluff Nursing Home
4401 North Main Street · Rockford, IL · 61103 · 8159219200
304 certified beds For profit - Corporation
Why this verdict
- 5 citations involved actual harm to residents.
- Staffing hours comfortably above national benchmarks.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 3 of 5 Staffing: 4 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 4.35 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.81 | 0.55–0.75 |
| Weekend hours / resident-day | 4.01 | ≈ weekday level |
| Nursing turnover / year | 41% | median 45% |
| Fines (3-yr window) | 1 · $10,199 |
Inspection citations (35 in the current record)
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Potential for harm · D April 22, 2026 · found via complaint
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.
Corrected May 4, 2026 · Quality of Life and Care
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Actual harm · G February 5, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected February 20, 2026 · Quality of Life and Care
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Actual harm · G February 5, 2026 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected February 20, 2026 · Quality of Life and Care
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Potential for harm · D February 5, 2026 · found via complaint
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected February 20, 2026 · Administration
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Potential for harm · D July 17, 2025 · found via complaint
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected July 29, 2025 · Environmental
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Potential for harm · D April 10, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected April 25, 2025 · Quality of Life and Care
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Potential for harm · D April 10, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected April 25, 2025 · Quality of Life and Care
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Potential for harm · D April 10, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 25, 2025 · Quality of Life and Care
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Potential for harm · D April 10, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected April 25, 2025 · Quality of Life and Care
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Potential for harm · D April 10, 2025
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.
Corrected April 25, 2025 · Quality of Life and Care
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Potential for harm · D April 10, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 25, 2025 · Pharmacy Service
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Potential for harm · D April 10, 2025
Provide and implement an infection prevention and control program.
Corrected April 25, 2025 · Infection Control
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Potential for harm · D December 23, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected January 9, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 13, 2024 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 6, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 20, 2024 · found via complaint
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.
Corrected July 2, 2024 · Resident Rights
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Actual harm · G May 14, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 31, 2024 · Quality of Life and Care
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Potential for harm · D May 14, 2024 · found via complaint
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected May 31, 2024 · Administration
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Actual harm · G March 7, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 29, 2024 · Quality of Life and Care
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Actual harm · G March 7, 2024
Provide enough food/fluids to maintain a resident's health.
Corrected March 29, 2024 · Quality of Life and Care
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Potential for harm · D March 7, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Corrected March 29, 2024 · Quality of Life and Care
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Potential for harm · E March 7, 2024
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.
Corrected March 29, 2024 · Pharmacy Service
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Potential for harm · D March 7, 2024
Provide and implement an infection prevention and control program.
Corrected March 29, 2024 · Infection Control
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Potential for harm · E March 7, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 26, 2024 · Quality of Life and Care
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Potential for harm · D October 16, 2023 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected November 6, 2023 · Quality of Life and Care
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Potential for harm · D June 8, 2023 · found via complaint
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.
Corrected June 22, 2023 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| May 14, 2024 | Fine | $10,199 |
| March 7, 2024 | Payment Denial | 21 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145771 · certified since April 8, 1993. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.