Starfile / Wisconsin

Rock River Nursing & Rehab

430 WILCOX ST, FORT ATKINSON, WI 53538 · CCN 525262

SFF

Inspection history vs Wisconsin & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$136,384

Number of fines

2

Number of penalties

5

Payment denials

3

Chain

Chain

BEDROCK HEALTHCARE

Facilities in chain

9

Chain avg overall

1.30 / 5

Inspection citations (120)5 immediate jeopardy5 actual harm

1. DF0610Respond appropriately to all alleged violations.2025-12-04 · Health · corrected 2026-01-13

   Potential for more than minimal harm

2. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-12-04 · Health · corrected 2026-01-13

   Potential for more than minimal harm

3. DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2025-12-04 · Health · corrected 2026-01-13

   Potential for more than minimal harm

4. KF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-07-23 · Health · corrected 2025-08-28

   Immediate jeopardy

5. CF0732Post nurse staffing information every day.2025-07-23 · Health · corrected 2025-08-28

   Potential for minimal harm

6. DF0745Provide medically-related social services to help each resident achieve the highest possible quality of life.2025-07-23 · Health · corrected 2025-08-28

   Potential for more than minimal harm

7. DF0942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.2025-07-23 · Health · corrected 2025-08-28

   Potential for more than minimal harm

8. DF0943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.2025-07-23 · Health · corrected 2025-08-28

   Potential for more than minimal harm

9. DF0944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.2025-07-23 · Health · corrected 2025-08-28

   Potential for more than minimal harm

10. EF0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.2025-07-23 · Health · corrected 2025-08-28

    Potential for more than minimal harm

11. DF0553Allow resident to participate in the development and implementation of his or her person-centered plan of care.2025-04-17 · Health · corrected 2025-05-23

    Potential for more than minimal harm

12. DF0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.2025-04-17 · Health · corrected 2025-05-23

    Potential for more than minimal harm

13. DF0610Respond appropriately to all alleged violations.2025-04-17 · Health · corrected 2025-05-23

    Potential for more than minimal harm

14. DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2025-04-17 · Health · corrected 2025-05-23

    Potential for more than minimal harm

15. JF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-04-17 · Health · corrected 2025-05-23

    Immediate jeopardy

16. GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2025-04-17 · Health · corrected 2025-05-23

    Actual harm

17. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-04-17 · Health · corrected 2025-05-23

    Actual harm

18. FF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2025-04-17 · Health · corrected 2025-05-23

    Potential for more than minimal harm

19. DF0757Ensure each resident’s drug regimen must be free from unnecessary drugs.2025-04-17 · Health · corrected 2025-05-23

    Potential for more than minimal harm

20. DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2025-04-17 · Health · corrected 2025-05-23

    Potential for more than minimal harm

21. FF0880Provide and implement an infection prevention and control program.2025-04-17 · Health · corrected 2025-05-23

    Potential for more than minimal harm

22. FF0882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.2025-04-17 · Health · corrected 2025-05-23

    Potential for more than minimal harm

23. DF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2025-04-17 · Health · corrected 2025-05-23

    Potential for more than minimal harm

24. EF0926Have policies on smoking.2025-04-17 · Health · corrected 2025-05-23

    Potential for more than minimal harm

25. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

26. EF0584Honor 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.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

27. DF0610Respond appropriately to all alleged violations.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

28. JF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-01-15 · Health · corrected 2025-05-23

    Immediate jeopardy

29. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

30. DF0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

31. FF0730Observe each nurse aide's job performance and give regular training.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

32. JF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2025-01-15 · Health · corrected 2025-02-13

    Immediate jeopardy

33. DF0759Ensure medication error rates are not 5 percent or greater.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

34. FF0837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

35. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

36. FF0941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

37. DF0942Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

38. DF0943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

39. FF0944Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

40. DF0945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

41. FF0946Provide training in compliance and ethics.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

42. FF0949Provide behavior health training consistent with the requirements and as determined by a facility assessment.2025-01-15 · Health · corrected 2025-02-13

    Potential for more than minimal harm

43. DF0552Ensure that residents are fully informed and understand their health status, care and treatments.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

44. DF0553Allow resident to participate in the development and implementation of his or her person-centered plan of care.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

45. DF0558Reasonably accommodate the needs and preferences of each resident.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

46. DF0559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

47. DF0563Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

48. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

49. EF0584Honor 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.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

50. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

51. DF0660Plan the resident's discharge to meet the resident's goals and needs.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

52. DF0676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

53. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

54. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

55. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

56. DF0699Provide care or services that was trauma informed and/or culturally competent.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

57. EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

58. EF0726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

59. DF0745Provide medically-related social services to help each resident achieve the highest possible quality of life.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

60. EF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

61. DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

62. DF0759Ensure medication error rates are not 5 percent or greater.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

63. CF0814Dispose of garbage and refuse properly.2024-09-11 · Health · corrected 2024-10-18

    Potential for minimal harm

64. DF0880Provide and implement an infection prevention and control program.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

65. FF0925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.2024-09-11 · Health · corrected 2024-10-18

    Potential for more than minimal harm

66. FF0837Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.2024-07-24 · Health · corrected 2024-08-15

    Potential for more than minimal harm

67. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-06-12 · Health · corrected 2024-07-16

    Potential for more than minimal harm

68. DF0585Honor 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.2024-06-12 · Health · corrected 2024-07-16

    Potential for more than minimal harm

69. DF0660Plan the resident's discharge to meet the resident's goals and needs.2024-06-12 · Health · corrected 2024-07-16

    Potential for more than minimal harm

70. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-06-12 · Health · corrected 2024-07-16

    Potential for more than minimal harm

71. GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-06-12 · Health · corrected 2024-10-21

    Actual harm

72. DF0687Provide appropriate foot care.2024-06-12 · Health · corrected 2024-07-16

    Potential for more than minimal harm

73. DF0880Provide and implement an infection prevention and control program.2024-06-12 · Health · corrected 2024-07-16

    Potential for more than minimal harm

74. DF0578Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

75. DF0610Respond appropriately to all alleged violations.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

76. DF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

77. EF0625Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

78. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

79. JF0678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.2024-04-25 · Health · corrected 2024-04-09

    Immediate jeopardy

80. GF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2024-04-25 · Health · corrected 2024-10-21

    Actual harm

81. EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

82. DF0692Provide enough food/fluids to maintain a resident's health.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

83. FF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

84. DF0742Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

85. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

86. DF0758Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

87. DF0761Ensure 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.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

88. DF0807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

89. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-04-25 · Health · corrected 2024-05-23

    Potential for more than minimal harm

90. DF0880Provide and implement an infection prevention and control program.2024-04-25 · Health · corrected 2024-07-16

    Potential for more than minimal harm

91. DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2024-03-07 · Health · corrected 2024-03-19

    Potential for more than minimal harm

92. DF0697Provide safe, appropriate pain management for a resident who requires such services.2024-03-07 · Health · corrected 2024-03-19

    Potential for more than minimal harm

93. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-02-21 · Health · corrected 2024-03-12

    Potential for more than minimal harm

94. EF0572Give residents a notice of rights, rules, services and charges.2023-12-12 · Health · corrected 2024-01-12

    Potential for more than minimal harm

95. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2023-12-12 · Health · corrected 2024-01-12

    Potential for more than minimal harm

96. DF0678Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.2023-12-12 · Health · corrected 2024-01-12

    Potential for more than minimal harm

97. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-12-12 · Health · corrected 2024-03-12

    Potential for more than minimal harm

98. DF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2023-12-12 · Health · corrected 2024-01-12

    Potential for more than minimal harm

99. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-12-12 · Health · corrected 2024-01-12

    Potential for more than minimal harm

100. DF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

101. DF0554Allow residents to self-administer drugs if determined clinically appropriate.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

102. DF0583Keep residents' personal and medical records private and confidential.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

103. EF0584Honor 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.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

104. EF0585Honor 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.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

105. DF0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

106. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

107. GF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-10-16 · Health · corrected 2024-03-12

     Actual harm

108. EF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

109. EF0759Ensure medication error rates are not 5 percent or greater.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

110. DF0760Ensure that residents are free from significant medication errors.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

111. FF0804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

112. EF0805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

113. DF0810Provide special eating equipment and utensils for residents who need them and appropriate assistance.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

114. FF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

115. FF0814Dispose of garbage and refuse properly.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

116. EF0825Provide or get specialized rehabilitative services as required for a resident.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

117. DF0880Provide and implement an infection prevention and control program.2023-10-16 · Health · corrected 2023-11-10

     Potential for more than minimal harm

118. DF0559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.2023-03-21 · Health · corrected 2023-04-15

     Potential for more than minimal harm

119. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-03-21 · Health · corrected 2023-04-15

     Potential for more than minimal harm

120. DF0695Provide safe and appropriate respiratory care for a resident when needed.2023-03-21 · Health · corrected 2023-04-15

     Potential for more than minimal harm

Ownership

Other facilities in FORT ATKINSON

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.