River Bluff Nursing Home

Penalties

• Feb 5, 2026 — IDPH fine (Nursing Home Care Act) ($2,200)
• May 14, 2024 — Fine ($10,199)
• May 14, 2024 — IDPH fine (Nursing Home Care Act) ($25,000)
• Mar 7, 2024 — Payment Denial · payment denial 21 days
• Mar 7, 2024 — IDPH fine (Nursing Home Care Act) ($2,200)
• Mar 7, 2024 — IDPH fine (Nursing Home Care Act) ($2,200)

Inspection findings

1. Jun 24, 2026 Health · 18 findings
   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0605 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     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 Jul 10, 2026 · CMS health inspection

   • Serious Scope/severity G

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0744 Quality of Life and Care Deficiencies

     Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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 Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0805 Nutrition and Dietary Deficiencies

     Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0133 Construction Deficiencies

     Install a two-hour-resistant firewall separation.

     Corrected Jul 7, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected Jul 7, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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.

     Corrected Jul 1, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Jul 7, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jul 7, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0754 Miscellaneous Deficiencies

     Provide properly sized and located linen or trash receptacles.

     Corrected Jul 7, 2026 · CMS fire safety

2. May 26, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0688 Quality of Life and Care Deficiencies

     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 Jun 1, 2026 · CMS health inspection

3. May 13, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 22, 2026 · CMS health inspection

4. Apr 22, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0688 Quality of Life and Care Deficiencies

     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 · CMS health inspection

5. Feb 5, 2026 Health · 4 findings
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 20, 2026 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected Feb 20, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0776 Administration Deficiencies

     Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

     Corrected Feb 20, 2026 · CMS health inspection

   • Not serious Scope/severity B

     Type B Illinois Nursing Home Care Act violation

     Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1010h), 300.1210b), and 300.1210d)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation:300.1210b) and 300.1210d)6).

     Statement of deficiencies (PDF)

6. Jul 17, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     Corrected Jul 29, 2025 · CMS health inspection

7. Apr 10, 2025 Fire Safety · 13 findings
   • Not serious Scope/severity F

     E0032 Emergency Preparedness Deficiencies

     Provide primary/alternate means for communication.

     Corrected May 15, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Apr 25, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Apr 25, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Apr 25, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     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 Apr 25, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0693 Quality of Life and Care Deficiencies

     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 Apr 25, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Apr 25, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Apr 25, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected May 15, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0311 Smoke Deficiencies

     Have an enclosure around a vertical opening shaft.

     Corrected May 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected May 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0915 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper power supply for life support equipment.

     Corrected Jun 9, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected May 15, 2025 · CMS fire safety

8. Dec 23, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Jan 9, 2025 · CMS health inspection

9. Nov 13, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Dec 6, 2024 · CMS health inspection

10. Jun 20, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0585 Resident Rights Deficiencies

      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 Jul 2, 2024 · CMS health inspection

11. May 14, 2024 Health · 3 findings
    • Serious Scope/severity G Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected May 31, 2024 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0776 Administration Deficiencies

      Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

      Corrected May 31, 2024 · CMS health inspection

    • Serious Scope/severity A

      Type A Illinois Nursing Home Care Act violation

      Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), 300.1210c), and 300.1210d)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.1210d)6).

      Statement of deficiencies (PDF)

12. Mar 7, 2024 Health · 11 findings
    • Serious Scope/severity G

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Mar 29, 2024 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Apr 26, 2024 · CMS health inspection

    • Serious Scope/severity G

      F0692 Quality of Life and Care Deficiencies

      Provide enough food/fluids to maintain a resident's health.

      Corrected Mar 29, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected Mar 29, 2024 · CMS health inspection

    • Not serious Scope/severity E

      F0761 Pharmacy Service Deficiencies

      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 Mar 29, 2024 · CMS health inspection

    • Not serious Scope/severity D

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Mar 29, 2024 · CMS health inspection

    • Not serious Scope/severity E

      K0281 Egress Deficiencies

      Install proper backup exit lighting.

      Corrected Apr 5, 2024 · CMS fire safety

    • Not serious Scope/severity F

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Apr 22, 2024 · CMS fire safety

    • Not serious Scope/severity B

      Type B Illinois Nursing Home Care Act violation

      Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1010h), 300.1210b), 300.1210c), and 300.1210d)2)5). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b) and 300.1210d)5).

      Statement of deficiencies (PDF)

    • Not serious Scope/severity B

      Type B Illinois Nursing Home Care Act violation

      Type B: more likely than not to cause more than minimal harm (1-130). Sections of the Illinois Administrative Code cited: 300.610a), 300.1010h), 300.1210b), and 300.1210c) and 300.1210d)3). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.1210b).

      Statement of deficiencies (PDF)

    • Not serious Scope/severity C

      Type C Illinois Nursing Home Care Act violation

      Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.650d). No Fine

      Statement of deficiencies (PDF)

13. Oct 16, 2023 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Nov 6, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• LOFGREN, MARK — w-2 managing employee, NOT APPLICABLE, since 06/10/2020
• LOFGREN, MARK — corporate director, NOT APPLICABLE, since 06/10/2020
• MCDIARMID, PATRICIA — corporate director, NOT APPLICABLE, since 04/01/2019
• COUNTY OF WINNEBAGO — operational/managerial control, NOT APPLICABLE, since 11/01/2008