Rock River Nursing & Rehab
430 Wilcox St, Fort Atkinson, WI 53538
Rock River Nursing & Rehab is a nursing home in Fort Atkinson, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 1 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 2 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (920) 563-5533
- Last standard health inspection
- May 6, 2026 (6 months ago)
- Certified beds
- 87
- Residents per day, on average
- 31.5
- Ownership type
- For profit - Corporation
- Legal business name
- Bedrock Hcs at Atkinson LLC
- Chain
- Bedrock Healthcare
- Takes part in
- Medicare and Medicaid
More health citations than the Wisconsin average (115 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Staffing
Total nurse staffing reported to CMS went from 4.4 to 3.8 hours per resident per day.
CMS update of October 8, 2026
Star rating
The CMS overall star rating changed from not rated by CMS to 1 of 5.
Star rating
The CMS health inspection star rating changed from not rated by CMS to 1 of 5.
Star rating
The CMS staffing star rating changed from not rated by CMS to 2 of 5.
Star rating
The CMS quality measures star rating changed from not rated by CMS to 2 of 5.
Special Focus Facility
CMS no longer lists this home as a Special Focus Facility.
7 citations
Health inspection on May 6, 2026
CMS lists this as a standard inspection.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on June 4, 2026.
CMS has cited this home for F0686 4 times since 2024.
Citation F0688. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on June 4, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on June 4, 2026.
CMS has cited this home for F0689 7 times since 2023.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on June 4, 2026.
CMS has cited this home for F0757 2 times since 2025.
Citation F0791. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain dental services for each resident.
CMS lists it as corrected on June 4, 2026.
Citation F0804. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on June 4, 2026.
CMS has cited this home for F0804 3 times since 2023.
Citation F0849. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
CMS lists it as corrected on June 4, 2026.
CMS update of February 25, 2026
Name
CMS lists a new name for this home. It was FORT ATKINSON CARE CENTER.
1 citation
Health inspection on February 6, 2026
CMS lists this as a complaint inspection.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on March 10, 2026.
3 citations
Health inspection on December 4, 2025
CMS lists this as a standard inspection and a complaint inspection.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on January 13, 2026.
CMS has cited this home for F0610 4 times since 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on January 13, 2026.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on January 13, 2026.
11 citations
Fire safety inspection on December 4, 2025
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on January 5, 2026.
CMS has cited this home for E0004 2 times since 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on January 9, 2026.
CMS has cited this home for K0345 3 times since 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on January 4, 2026.
CMS has cited this home for K0353 3 times since 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on January 4, 2026.
CMS has cited this home for K0712 3 times since 2024.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on January 4, 2026.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on January 4, 2026.
CMS has cited this home for K0918 3 times since 2024.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on January 5, 2026.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on February 6, 2026.
CMS has cited this home for K0374 3 times since 2024.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on December 19, 2025.
CMS has cited this home for K0324 3 times since 2024.
Citation K0351. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install an approved automatic sprinkler system.
CMS lists it as corrected on January 5, 2026.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on January 4, 2026.
CMS has cited this home for K0511 2 times since 2025.
Payment stopped
August 22, 2025 (1 year ago)
CMS stopped payment for new admissions from August 22, 2025, for 6 days.
CMS update of July 30, 2025
Staffing
Total nurse staffing reported to CMS went from 3.8 to 3.3 hours per resident per day.
7 citations
Health inspection on July 23, 2025
CMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0689. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 28, 2025.
Citation F0949. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on August 28, 2025.
CMS has cited this home for F0949 2 times since 2025.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on August 28, 2025.
CMS has cited this home for F0745 2 times since 2024.
Citation F0942. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
CMS lists it as corrected on August 28, 2025.
CMS has cited this home for F0942 2 times since 2025.
Citation F0943. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on August 28, 2025.
CMS has cited this home for F0943 2 times since 2025.
Citation F0944. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on August 28, 2025.
CMS has cited this home for F0944 2 times since 2025.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on August 28, 2025.
Fine
July 23, 2025 (1 year ago)
CMS fine of $91,960 on July 23, 2025.
CMS update of June 25, 2025
Health citation
CMS removed citation F0623 from the health inspection on April 25, 2024.
Health citation
CMS removed citation F0625 from the health inspection on April 25, 2024.
Health citation
CMS removed citation F0758 from the health inspection on April 25, 2024.
CMS update of May 28, 2025
Fine
CMS changed the fine from April 25, 2024 from $116,961 to $119,142.
14 citations
Health inspection on April 17, 2025
CMS lists this as a standard inspection and a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 23, 2025.
CMS has cited this home for F0684 6 times since 2023.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on May 23, 2025.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on May 23, 2025.
Citation F0725. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on May 23, 2025.
CMS has cited this home for F0725 3 times since 2023.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 23, 2025.
CMS has cited this home for F0880 5 times since 2023.
Citation F0882. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
CMS lists it as corrected on May 23, 2025.
Citation F0926. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have policies on smoking.
CMS lists it as corrected on May 23, 2025.
Citation F0553. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
CMS lists it as corrected on May 23, 2025.
CMS has cited this home for F0553 2 times since 2024.
Citation F0604. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS lists it as corrected on May 23, 2025.
CMS has cited this home for F0604 2 times since 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on May 23, 2025.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on May 23, 2025.
Citation F0757. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident’s drug regimen must be free from unnecessary drugs.
CMS lists it as corrected on May 23, 2025.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement 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.
CMS lists it as corrected on May 23, 2025.
CMS has cited this home for F0758 2 times since 2024.
Citation F0883. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on May 23, 2025.
19 citations
Fire safety inspection on April 17, 2025
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on May 16, 2025.
Citation E0007. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Address patient/client population and determine types of services needed.
CMS lists it as corrected on May 23, 2025.
Citation E0013. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop Emergency Preparedness policies and procedures.
CMS lists it as corrected on May 23, 2025.
Citation E0025. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Create arrangements with other facilities to receive patients.
CMS lists it as corrected on May 23, 2025.
Citation E0031. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide emergency officials' contact information.
CMS lists it as corrected on May 23, 2025.
Citation E0036. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish emergency prep training and testing.
CMS lists it as corrected on May 23, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on June 6, 2025.
Citation K0354. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
CMS lists it as corrected on June 1, 2025.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on May 23, 2025.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on June 11, 2025.
Citation K0347. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Properly provide smoke detection systems in areas open to corridors.
CMS lists it as corrected on June 13, 2025.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on June 9, 2025.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on July 10, 2025.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 13, 2025.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on May 23, 2025.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on June 1, 2025.
Citation K0741. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
CMS lists it as corrected on May 23, 2025.
Citation K0781. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of portable space heaters.
CMS lists it as corrected on June 26, 2025.
Citation K0925. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
CMS lists it as corrected on May 23, 2025.
CMS update of March 26, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to not rated by CMS.
Star rating
The CMS health inspection star rating changed from 1 of 5 to not rated by CMS.
Star rating
The CMS staffing star rating changed from 1 of 5 to not rated by CMS.
Star rating
The CMS quality measures star rating changed from 1 of 5 to not rated by CMS.
Special Focus Facility
CMS now lists this home as a Special Focus Facility.
CMS update of February 26, 2025
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Staffing
Total nurse staffing reported to CMS went from 3.6 to 3.2 hours per resident per day.
Fine
CMS changed the fine from April 25, 2024 from $57,090 to $116,961.
18 citations
Health inspection on January 15, 2025
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on May 23, 2025.
Citation F0755. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on February 13, 2025.
CMS has cited this home for F0755 3 times since 2024.
Citation F0730. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on February 13, 2025.
Citation F0837. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish 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.
CMS lists it as corrected on February 13, 2025.
CMS has cited this home for F0837 2 times since 2024.
Citation F0941. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
CMS lists it as corrected on February 13, 2025.
Citation F0944. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
CMS lists it as corrected on February 13, 2025.
Citation F0946. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide training in compliance and ethics.
CMS lists it as corrected on February 13, 2025.
Citation F0949. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
CMS lists it as corrected on February 13, 2025.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on February 13, 2025.
CMS has cited this home for F0584 3 times since 2023.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on February 13, 2025.
CMS has cited this home for F0580 4 times since 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on February 13, 2025.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on February 13, 2025.
Citation F0726. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS lists it as corrected on February 13, 2025.
CMS has cited this home for F0726 2 times since 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on February 13, 2025.
CMS has cited this home for F0759 3 times since 2023.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on February 13, 2025.
Citation F0942. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
CMS lists it as corrected on February 13, 2025.
Citation F0943. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
CMS lists it as corrected on February 13, 2025.
Citation F0945. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
CMS lists it as corrected on February 13, 2025.
1 citation
Fire safety inspection on January 15, 2025
CMS lists this as a complaint inspection.
Citation K0500. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet other general requirements that are deficient.
CMS lists it as corrected on February 21, 2025.
CMS update of December 20, 2024
Special Focus Facility
CMS now lists this home as a Special Focus Facility candidate.
CMS abuse icon
CMS removed its abuse icon from this home.
CMS update of October 30, 2024
Fine
CMS changed the fine from January 14, 2023 from $118,036 to $121,831.
Fine
CMS changed the fine from October 16, 2023 from $16,801 to $17,243.
23 citations
Health inspection on September 11, 2024
CMS lists this as a complaint inspection.
Citation F0925. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
CMS lists it as corrected on October 18, 2024.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on October 18, 2024.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on October 18, 2024.
Citation F0726. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
CMS lists it as corrected on October 18, 2024.
Citation F0755. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on October 18, 2024.
Citation F0552. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are fully informed and understand their health status, care and treatments.
CMS lists it as corrected on October 18, 2024.
Citation F0553. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
CMS lists it as corrected on October 18, 2024.
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on October 18, 2024.
Citation F0559. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
CMS lists it as corrected on October 18, 2024.
Citation F0563. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
CMS lists it as corrected on October 18, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on October 18, 2024.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on October 18, 2024.
Citation F0660. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Plan the resident's discharge to meet the resident's goals and needs.
CMS lists it as corrected on October 18, 2024.
CMS has cited this home for F0660 2 times since 2024.
Citation F0676. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
CMS lists it as corrected on October 18, 2024.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on October 18, 2024.
CMS has cited this home for F0677 2 times since 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on October 18, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on October 18, 2024.
Citation F0699. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care or services that was trauma informed and/or culturally competent.
CMS lists it as corrected on October 18, 2024.
Citation F0745. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide medically-related social services to help each resident achieve the highest possible quality of life.
CMS lists it as corrected on October 18, 2024.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Implement 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.
CMS lists it as corrected on October 18, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on October 18, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on October 18, 2024.
Citation F0814. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on October 18, 2024.
CMS has cited this home for F0814 2 times since 2023.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Fine
CMS changed the fine from January 14, 2023 from $114,240 to $118,036.
Fine
CMS changed the fine from October 16, 2023 from $25,847 to $16,801.
1 citation
Health inspection on July 24, 2024
CMS lists this as a complaint inspection.
Citation F0837. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish 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.
CMS lists it as corrected on August 15, 2024.
7 citations
Health inspection on June 12, 2024
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
67 of 323 Wisconsin homes (21%) got a citation at the actual harm level in 2024.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on October 21, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on July 16, 2024.
Citation F0585. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 16, 2024.
CMS has cited this home for F0585 2 times since 2023.
Citation F0660. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Plan the resident's discharge to meet the resident's goals and needs.
CMS lists it as corrected on July 16, 2024.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 16, 2024.
Citation F0687. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate foot care.
CMS lists it as corrected on July 16, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 16, 2024.
Payment stopped
May 24, 2024 (2 years ago)
CMS stopped payment for new admissions from May 24, 2024, for 150 days.
7 citations
Health inspection on April 25, 2024
CMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
64 of 323 Wisconsin homes (20%) got a citation at the immediate jeopardy level in 2024.
Citation F0678. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
CMS lists it as corrected on April 9, 2024.
CMS has cited this home for F0678 2 times since 2023.
Citation F0686. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on October 21, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on May 23, 2024.
CMS has cited this home for F0812 3 times since 2023.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on May 23, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on May 23, 2024.
Citation F0807. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
CMS lists it as corrected on May 23, 2024.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 16, 2024.
15 citations
Fire safety inspection on April 25, 2024
CMS lists this as a standard inspection.
Citation E0006. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on May 23, 2024.
Citation K0291. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on May 23, 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on May 23, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on May 23, 2024.
Citation K0911. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on May 23, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on May 23, 2024.
Citation K0920. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on May 23, 2024.
Citation K0923. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on May 23, 2024.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on May 23, 2024.
Citation K0222. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 23, 2024.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on May 23, 2024.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on May 23, 2024.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on May 23, 2024.
Citation K0919. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on May 23, 2024.
Citation K0345. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on May 23, 2024.
Fine
April 25, 2024 (2 years ago)
CMS fine of $119,141 on April 25, 2024.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
2 citations
Health inspection on March 7, 2024
CMS lists this as a complaint inspection.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on March 19, 2024.
Citation F0697. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe, appropriate pain management for a resident who requires such services.
CMS lists it as corrected on March 19, 2024.
1 citation
Health inspection on February 21, 2024
CMS lists this as a complaint inspection.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on March 12, 2024.
CMS update of January 31, 2024
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5.
6 citations
Health inspection on December 12, 2023
CMS lists this as a complaint inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on January 12, 2024.
Citation F0572. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Give residents a notice of rights, rules, services and charges.
CMS lists it as corrected on January 12, 2024.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on January 12, 2024.
Citation F0678. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
CMS lists it as corrected on January 12, 2024.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 12, 2024.
Citation F0804. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on January 12, 2024.
18 citations
Health inspection on October 16, 2023
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
42 of 323 Wisconsin homes (13%) got a citation at the actual harm level in 2023.
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on March 12, 2024.
Citation F0804. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS lists it as corrected on November 10, 2023.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on November 10, 2023.
Citation F0814. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on November 10, 2023.
Citation F0584. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 10, 2023.
Citation F0585. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on November 10, 2023.
Citation F0725. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
CMS lists it as corrected on November 10, 2023.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on November 10, 2023.
Citation F0805. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on November 10, 2023.
Citation F0825. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide or get specialized rehabilitative services as required for a resident.
CMS lists it as corrected on November 10, 2023.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on November 10, 2023.
Citation F0554. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Allow residents to self-administer drugs if determined clinically appropriate.
CMS lists it as corrected on November 10, 2023.
Citation F0583. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep residents' personal and medical records private and confidential.
CMS lists it as corrected on November 10, 2023.
Citation F0604. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS lists it as corrected on November 10, 2023.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on November 10, 2023.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on November 10, 2023.
Citation F0810. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
CMS lists it as corrected on November 10, 2023.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on November 10, 2023.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- CHOPP, MARTIN5% or greater indirect ownership interest · 20% · since 10/01/2019
- CHOPP, PNINA5% or greater indirect ownership interest · 60% · since 10/01/2019
- CHOPP, SOLOMON5% or greater indirect ownership interest · 20% · since 10/01/2019
- OPAL HEALTHCARE WI LLCOperational/managerial control · not applicable · since 10/01/2019
- BREWER, ANTHONYOperational/managerial control · not applicable · since 07/08/2025
- CHOPP, MARTINOperational/managerial control · not applicable · since 10/01/2019
- CHOPP, PNINAOperational/managerial control · not applicable · since 10/01/2019
- CHOPP, SOLOMONOperational/managerial control · not applicable · since 10/01/2019
- RAMANUJAM, SANDEEPOperational/managerial control · not applicable · since 02/01/2024
Questions
When was Rock River Nursing & Rehab last inspected?
CMS lists May 6, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Rock River Nursing & Rehab have?
CMS lists 115 health citations since October 16, 2023. CMS also calls these deficiencies.
Has Rock River Nursing & Rehab been fined?
CMS lists 2 fines in the past three years, $211,101 in total.
What is the CMS star rating of Rock River Nursing & Rehab?
Its CMS overall star rating is 1 of 5.
Is Rock River Nursing & Rehab a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.