Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rock Falls Rehab & Hlth Care C during CMS and state inspections, most recent first.
The facility failed to provide adequate notice to residents and their families before transferring them due to a sudden closure. Six residents, with various medical conditions, were given only two to three days to relocate, causing significant emotional distress. The facility's policy requires a 30-day notice, but the new owners mandated a rapid discharge, leading to confusion and upset among residents and their families.
A facility failed to administer prescribed fluoxetine to a resident with major depressive disorder, leading to suicidal ideation and hospitalization. Additionally, an LPN withheld lisinopril from another resident due to low blood pressure but failed to assess, re-check, or notify the physician, contrary to facility policy.
The facility did not maintain 8-hour consecutive RN coverage 7 days a week, impacting all residents. The DON often worked nights instead of days, leading to gaps in RN coverage, especially on weekends. Staffing records showed inconsistencies, and the BOM cited issues with the payroll system's reliability.
The facility failed to store medications safely, with unlabeled antibiotics found in a medication cart and improper temperature control in the medication refrigerator. The refrigerator contained morphine for two residents and other stock medications, with no recent temperature logs maintained. The DON acknowledged the importance of temperature checks but had not ensured compliance with the facility's policies.
The facility failed to ensure dietary staff completed food safety training, affecting all residents. The Dietary Manager acknowledged that two staff members alternated roles, but one was new and had not completed training, while the other's certification had expired. The Administrator expected staff to have current training, but it was the Dietary Manager's responsibility to ensure this. Job descriptions required food handler training within 30 days of employment, which was not met.
The facility failed to properly sanitize dishes and prevent chemical contamination of food, affecting all residents. The dishwasher did not reach the required temperature, and the chlorine sanitizer level was inadequate. The 3-compartment sink was improperly set up, leading to sanitizing liquid dripping into pureed food prepared for residents. This posed a potential health risk, as ingestion of the sanitizer could cause nausea.
The facility failed to maintain a safe and sanitary environment, with structural issues like ceiling holes and a leaking roof affecting all residents. Staff and residents reported prolonged inaction, and a resident with complex medical needs was exposed to a dusty fan due to unclear cleaning responsibilities.
A facility failed to follow infection control protocols, including improper cleaning of glucometers between residents, inadequate hand hygiene, and failure to adhere to Enhanced Barrier Precautions. An LPN used a glucometer on multiple residents without proper disinfection, and staff did not change gloves during incontinence care, risking cross-contamination.
A resident with multiple health conditions did not receive a bed hold notice after being hospitalized, as required by the facility's policy. The DON confirmed the absence of a signed notification in the resident's chart, despite the policy stating it should be issued at discharge or within 24 hours.
A resident with dysphagia was found feeding herself in bed at an improper angle, risking choking, due to lack of supervision and inadequate care planning. CNAs were not present to assist, and the care plan lacked necessary swallowing precautions. The facility's policies did not adequately address these needs, and no speech therapy evaluation was available.
The facility failed to manage tube feeding properly for two residents. One resident's feeding was not paused during a tracheostomy change, risking aspiration, while another resident's feeding tube site was not cleaned or dressed as required, leading to redness and drainage. Both residents have complex medical conditions requiring careful nutritional management.
The facility failed to provide adequate respiratory care for two residents. One resident with a tracheostomy did not have a smaller-sized trach tube at the bedside, which is necessary in emergencies. Another resident on oxygen therapy had outdated equipment and lacked oxygen saturation monitoring. The facility's policies on tracheostomy care and oxygen therapy were not properly followed, leading to these deficiencies.
A resident with multiple health conditions did not have an adequate supply of lactulose, leading an LPN to use another resident's medication to complete the dose. This was administered via gastric tube and documented, despite the DON stating that borrowing medication is unsafe and against proper medication administration practices.
Inadequate Notice for Resident Transfers Due to Facility Closure
Penalty
Summary
The facility failed to provide appropriate notice to residents and their representatives prior to transferring them to another facility. This deficiency affected six residents, leading to psychosocial harm, confusion, and distress. The facility informed residents and their families on November 4, 2024, that they had only two to three days to find alternative placements due to the facility's closure. This short notice was contrary to the facility's policy, which requires a 30-day notice for transfers or discharges initiated by the facility. The residents involved had various medical conditions, including Alzheimer's disease, schizoaffective disorder, anoxic brain damage, and cerebral palsy, among others. The abrupt transfer process caused significant emotional distress for the residents and their families. For instance, one resident's sister, who is also her power of attorney, reported that the resident was confused and scared after being moved to a new facility. Another resident's mother expressed distress over the short notice and the distance of the new placement from her home. The facility's administration and staff were informed of the closure by the new owners on November 4, 2024, and were instructed to discharge all residents by November 6, 2024. This rapid turnaround did not allow for adequate preparation or consideration of the residents' emotional and psychological needs. The facility's failure to adhere to its own transfer and discharge policy resulted in a chaotic and distressing experience for the residents and their families.
Medication Administration Failures Lead to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of major depressive disorder received her prescribed medication, fluoxetine, which resulted in the resident experiencing suicidal ideation and being sent to a local emergency room for evaluation. The resident, identified as R8, had a history of depression and was supposed to receive an increased dose of fluoxetine from 60 mg to 80 mg daily as per the physician's order. However, due to a pending order status, the staff was unaware of the dose increase, and R8 did not receive the medication for six days. This lapse in medication administration was confirmed by the Director of Nursing, who acknowledged the potential for severe reactions, including increased depression and suicidal thoughts, if medications are not administered as ordered. Another deficiency involved the failure to notify a physician and assess a resident, identified as R21, after holding a blood pressure medication, lisinopril. An LPN, V3, decided to withhold the medication after observing a low blood pressure reading of 99/56, which was lower than the resident's usual range. Despite this, V3 did not perform any further assessment, re-check the blood pressure later, or notify the physician about the held medication. The Director of Nursing confirmed that without specific parameters set by the physician, the nurse should have re-checked the blood pressure, performed an assessment, and informed the physician of the held medication. The facility's Medication Administration Policy requires that physicians and licensed nursing personnel administer drugs and biologicals, and that the physician be notified as soon as practical when a scheduled dose of medication has not been administered. In this case, the LPN failed to document the low blood pressure, the decision to hold the medication, or any follow-up assessments, which was acknowledged by the Director of Nursing as a failure to adhere to the facility's policy.
Deficiency in RN Coverage at Facility
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours, 7 days a week, affecting all residents. The CMS 671 Form indicated that 21 residents were residing in the facility. The CMS PBJ Staffing Data Report for Quarter 2 revealed that the facility had no RN hours during this period. The Director of Nursing (DON) admitted to covering open shifts and call-offs, often working nights instead of days, and acknowledged that there might have been weekends without RN coverage. A review of the facility's monthly working schedule, timecards, and Labor Detail Report showed inconsistencies and confirmed the absence of 8-hour consecutive RN coverage on specific dates, primarily weekends. The Business Office Manager (BOM) noted the payroll system's unreliability, contributing to the confusion in staffing records.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications safely and in accordance with professional principles, which could potentially affect all 21 residents. During an inspection, it was observed that a medication cart contained two cephalexin capsules without any resident or pharmacy identifiers, and a bottle of eye drops labeled for a specific resident with an opened date. Additionally, the medication refrigerator was found to have a temperature of 44 degrees, with ice buildup in the freezer section and melted popsicles, indicating improper temperature control. The refrigerator contained bottles of morphine labeled for two residents, along with stock medications such as tubersol, insulin, suppositories, and injectables. The facility's Director of Nursing acknowledged the importance of checking refrigerator temperatures twice daily to prevent damage or efficacy alteration of medications. However, the temperature log had not been completed since a previous date, and there were no complete logs for several months. The facility's policy requires medications to be labeled with specific information and for discontinued or expired medications to be removed from active storage. The failure to adhere to these policies and maintain proper storage conditions led to the deficiency.
Deficiency in Dietary Staff Training
Penalty
Summary
The facility failed to ensure that dietary staff completed the necessary food safety training, affecting all residents in the building. The CMS 671 form indicated that there were 21 residents in the facility. During the survey, the Dietary Manager (V7) acknowledged that two staff members, V8 and V9, alternated between cooking and dietary aide duties. However, V8, who was new to the facility, had not completed her food safety training, and V9's certification had expired. V8 mentioned that she informed the facility during her interview about her expired certification, but the facility had not arranged for her training. The Dietary Manager stated that it was the responsibility of the staff to keep their training up-to-date, and the facility did not pay for training. The Administrator (V1) expected the dietary staff to have current food handler training and indicated that the training could be completed online through the food service contractor's website. However, it was the Dietary Manager's responsibility to ensure that her staff's training and certifications were current. The job descriptions for both the Cook/Dietary Aide and Dietary Aide positions required food handler training within 30 days of employment, which was not adhered to in this case.
Improper Dish Sanitization and Chemical Contamination of Food
Penalty
Summary
The facility failed to ensure proper sanitation of dishes and prevent chemical contamination of food, affecting all residents. During a kitchen tour, the Dietary Manager and Cook/Dietary Aide demonstrated improper use of the dishwasher and 3-compartment sink. The dishwasher was not reaching the required temperature of 135 degrees Fahrenheit, and the chlorine sanitizer level was consistently below the necessary 50-100 PPM, indicating inadequate sanitization of dishes. Despite multiple attempts to rectify the issue, the sanitizer was not being dispensed correctly due to a potential problem with the hose. Additionally, the 3-compartment sink was not set up correctly, with the sanitizer level exceeding the recommended 200 PPM, and there was no designated drying area. The Cook/Dietary Aide failed to submerge the blending container in the sanitizing sink for the required 30 seconds and did not allow it to air dry. This led to sanitizing liquid dripping into the pureed food prepared for residents, which could pose a health risk. The facility's policies for ware-washing and the use of the 3-compartment sink were not followed, resulting in potential chemical contamination of food. The Dietary Manager acknowledged that the sanitizing liquid should not be present in the food and that ingestion could cause nausea. The residents affected by this deficiency were those on pureed diets, specifically identified as R1, R6, and R17.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment, affecting all residents. Observations revealed significant structural issues, including a large hole in the ceiling of the main dining area and another in the activity room, both with plastic tunnels leading to garbage cans. The surrounding ceiling areas showed signs of water damage, such as bubbling and peeling drywall. The roof was in disrepair, with missing or damaged shingles, allowing water to enter the facility. The Maintenance Director, on his first day, acknowledged the leaks and suggested temporary fixes, but the issues had persisted for weeks to months without resolution. Interviews with staff and residents confirmed the prolonged nature of the problem. A CNA reported the holes had been present for weeks to months, and residents expressed concerns about the lack of communication and action from facility management. The Administrator admitted the roof was leaking and required replacement, but no maintenance policy or repair log was in place. An email from the Regional Maintenance indicated that temporary repairs had been made, but permanent solutions were pending. Additionally, a resident with complex medical needs, including a tracheostomy, was found in a room with a dusty fan blowing directly on them. The fan had not been cleaned in a long time due to staffing shortages and unclear responsibilities between housekeeping and maintenance. The resident's care plan highlighted their vulnerability due to multiple health conditions, yet the facility failed to ensure a clean environment, as required by their housekeeping job summary.
Infection Control Deficiencies in Glucometer Use and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, particularly in the use and cleaning of glucometers. An LPN was observed using a glucometer on multiple residents without adequately cleaning it between uses. The glucometer was loosely wrapped in a white wipe and not wiped with a bleach wipe before or after use, leading to potential cross-contamination. The facility's policy required the glucometer to be cleaned with a germicidal disposable wipe between each resident test, which was not followed. Additionally, the facility failed to maintain proper hand hygiene and G-tube positioning. An LPN was observed using excessive hand sanitizer and wiping it on her scrub pants instead of rubbing it in completely. During the administration of G-tube medications, the LPN placed the feeding tube directly on a resident's gown without a cap, increasing the risk of contamination. The facility's policy required hand sanitizer to be rubbed over all surfaces of the hands until dry and the feeding tube to be kept clean and off the resident. The facility also did not adhere to Enhanced Barrier Precautions (EBP) for residents requiring such measures. Staff were observed providing care to a resident with a tracheostomy without wearing gowns, despite the EBP sign on the resident's door. The facility's policy required gowns and gloves for high-contact care activities, which was not followed. Furthermore, during incontinence care, staff failed to change gloves between tasks, risking contamination. The facility's policy required gloves to be changed after incontinence care and before touching anything else.
Failure to Issue Bed Hold Notice
Penalty
Summary
The facility failed to issue a bed hold notice to a resident who was transferred to a hospital, as required by their policy. The resident, a cognitively intact [AGE] year-old female with multiple diagnoses including major depressive disorder, schizoaffective disorder, bipolar type, generalized anxiety disorder, osteoarthritis, hypertension, type 2 diabetes, and chronic obstructive pulmonary disease, reported not receiving a bed hold notice after her hospitalization. The Director of Nursing confirmed that there was no signed bed hold notification in the resident's chart and acknowledged the importance of issuing such notifications to inform residents of their bed status. The facility's policy mandates that a bed hold notice be given at the time of discharge or within 24 hours, but this was not documented in the resident's medical record.
Failure to Supervise and Position Resident with Dysphagia
Penalty
Summary
The facility failed to ensure proper supervision and positioning for a resident with dysphagia who was on a pureed diet. On the observed date, the resident was found lying in bed with the head of the bed at 45 degrees while feeding herself, which is contrary to the requirement of sitting upright at 90 degrees to prevent choking. The resident expressed awareness that her bed should be higher but continued eating regardless. Certified Nursing Assistants (CNAs) were present in the hallway and not supervising the resident, and upon inquiry, one CNA adjusted the bed to the correct position, acknowledging the resident should be sitting upright to avoid choking. Further investigation revealed that the resident's care plan did not include specific swallowing precautions or positioning needs for eating, despite her history of dysphagia and a stroke. The Dietary Manager confirmed the absence of a speech therapy evaluation and noted issues with therapy services at the facility. The Director of Nursing also confirmed the resident's need to be upright while eating to prevent aspiration. The facility's policies on swallow evaluation and therapeutic diets did not adequately address swallowing or aspiration precautions, contributing to the oversight in the resident's care plan.
Deficiencies in Tube Feeding Management and Site Care
Penalty
Summary
The facility failed to ensure proper management of tube feeding for a resident, R11, during a tracheostomy change. On the morning of September 3, 2024, R11's tube feeding was observed to be infusing at 60 ml per hour while the head of the bed was flat, contrary to aspiration precautions. The Licensed Practical Nurse (LPN) and Respiratory Therapist involved did not pause the tube feeding during the procedure, which is a necessary step to prevent aspiration when the resident's head is not elevated. The Director of Nursing later confirmed that tube feeding should be paused during such care activities. The care plan and physician orders for R11 did not specify the need to keep the head of the bed elevated during tube feeding, contributing to the oversight. Another deficiency was identified with resident R14, whose feeding tube site care was neglected. On September 4, 2024, R14 was found without a dressing at the feeding tube site, which exhibited serous fluid, redness, and a dried, caked substance. The Director of Nursing acknowledged the site was not clean and lacked a dressing, as required by the physician's orders. The LPN admitted to not having cleaned the site, despite a reminder in the medical record to perform this task daily. The care plan for R14 indicated the need for daily cleaning and dressing of the g-tube site, which was not adhered to. Both residents, R11 and R14, have complex medical histories that necessitate careful management of their nutritional needs through tube feeding. R11's conditions include anoxic brain damage, chronic respiratory failure, and cerebral palsy, while R14 has multiple sclerosis and other significant health issues. The facility's failure to follow proper procedures for tube feeding management and site care for these residents highlights a lapse in adhering to established care protocols, potentially compromising their health and safety.
Deficiencies in Respiratory Care for Residents with Tracheostomy and Oxygen Therapy
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents, R11 and R6, who required tracheostomy and oxygen therapy, respectively. For R11, the facility did not have a smaller-sized tracheostomy tube at the bedside, which is crucial in case of an emergency where the current trach might not fit due to swelling. During a trach change, it was observed that only size 6 tracheostomies were available, and the required size 4 was missing. The facility's policy did not specify the need for a smaller trach at the bedside, and R11's care plan lacked details on the trach size, type, and emergency procedures. For R6, the facility did not change the respiratory care equipment weekly as required. The nasal cannula and oxygen humidifier bottle were dated several weeks prior, indicating they had not been changed. Additionally, there was no monitoring of oxygen saturations for R6, who was on as-needed oxygen therapy. The staff, including a Registered Nurse and Certified Nursing Assistants, confirmed that oxygen was used regularly at night and during naps, but no oxygen saturation readings were recorded in September, and the last recorded reading was in early August. The facility's policies on tracheostomy care and oxygen therapy were not adequately followed, leading to deficiencies in the care provided to R11 and R6. The lack of a smaller trach at the bedside for R11 and the failure to change respiratory equipment and monitor oxygen saturations for R6 highlight significant lapses in ensuring safe and appropriate respiratory care for residents.
Inadequate Medication Supply and Improper Administration
Penalty
Summary
The facility failed to maintain an adequate supply of medication for a resident, leading to inappropriate medication administration. A male resident with multiple sclerosis, gastrostomy status, severe sepsis, and major depressive disorder was prescribed lactulose concentrate, 60 ml twice daily. During medication preparation, an LPN discovered that the resident's lactulose bottle was empty and no additional supply was available in the medication cart. The LPN then used another resident's lactulose bottle to complete the dose for the first resident, which was administered via gastric tube. This action was verbally confirmed by the LPN and documented in the medication administration record. The Director of Nursing later stated that borrowing medication from another resident is not acceptable practice, as it is unsafe and does not adhere to the five rights of medication administration.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 133 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rock Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Citadel Of Sterling,the | 2.5 mi | ★★★★★ | 0 | 0 |
| Allure Of Sterling | 2.7 mi | ★★★★★ | 15 | 1 |
| La Bella Of Sterling | 2.9 mi | ★★★★★ | 2 | 0 |
| Heritage Square | 10.8 mi | ★★★★★ | 9 | 0 |
| Dixon Rehab & Hcc | 10.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rock Falls Rehab & Hlth Care C.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.